Paradigm at The Pines

In the surveyor’s words

From the most serious findings on record at Paradigm at The Pines, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 10, 2025

  Based on interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 3 residents reviewed for accidents and supervision. (Resident #1)The facility failed to provide adequate supervision for Resident #1 who was assessed as a high risk for elopement. On 03/23/25 CNA B who was assigned to cover the unit left the unit leaving the residents unattended. Resident #1 eloped from the unit and was found at his previous home address sitting on the porch steps approximately 1 mile from the facility. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 03/23/25 and ended on 03/27/25. The facility had corrected the non-compliance before the survey began. […]

• No harm, potential for more than minimal, widespreadF727Sep 20, 2023

  Based on interview and record review the facility failed to ensure they had a full time DON and failed to ensure the had an RN for 8 consecutive hours 7 days a week for 6 of 6 months reviewed for RN coverage. * The facility did not have a full-time DON between 9/02/23 and 9/18/23. * The facility did not have RN coverage for 8 consecutive hours on Saturday and Sunday. These failures could place residents at risk of lack of nursing oversight and a higher level of care. 1. During an interview upon entrance on 09/18/23 at 08:46 a.m. the ADM said she had no full time DON and will call to try and get interim back. During an interview on 09/19/23 at 10:35 a.m. the ADM said the previous DON's last day was 07/21/23. She said the Interim DON originally began on 07/24/23. […]

• No harm, potential for more than minimal, widespreadF801Sep 20, 2023

  Based on interview and record review, the facility failed to employ sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 1 of 1 facility kitchen. The facility failed to designate a person to serve as the Dietary Manager who met the required qualifications. The facility designated Dietary Manager did not have a Dietary Managers certification or any other qualifying credentials. This failure could place residents at risk for the spread of foodborne illness and residents not having their nutritional needs met. […]

• No harm, potential for more than minimal, widespreadF812Sep 20, 2023

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the kitchen reviewed for dietary services. The facility failed to prevent the following: Two of 4 freezers had 3-to-4-inch layer of buildup of ice. The juice dispenser nozzle (gun) had thick buildup of black and red substance on the inside of the nozzle. The deep fryer contained very dark grease with particles of food debris and had an odor. Food items were not properly labeled with product and expiration date in the refrigerator. The grates on the stove had buildup of black substance. These failures could place residents, who ate meals prepared in the kitchen, at risk for food borne illness. […]

• No harm, potential for more than minimal, widespreadF851Sep 20, 2023

  Based on interview and record review the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. The facility failed to submit direct care staffing information on the schedule specified by CMS (Centers for Medicare and Medicaid Services), but no less frequently than quarterly for 1 of 3 quarters reviewed for payroll data information. *The facility failed to submit staffing information to CMS for the 3rd quarter of the fiscal year 2023. This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. […]