A list of the most recent deficiencies for Paradigm at Woodwind Lakes. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-10 | 2024-02-17 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-01-10 | 2024-02-17 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-01-10 | 2024-02-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-10 | 2024-02-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-01-10 | 2024-02-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-10 | 2024-02-17 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-01-09 | 2024-02-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-09 | 2024-02-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-09 | 2024-02-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-01-09 | 2024-02-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-01-09 | 2024-02-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-01-09 | 2024-02-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-09 | 2024-02-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-09 | 2024-02-17 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-08-04 | 2023-08-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-04 | 2023-08-07 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-08-04 | 2023-08-07 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-08-04 | 2023-08-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-23 | 2023-07-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-17 | 2023-07-19 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-17 | 2023-07-19 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-17 | 2023-07-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-17 | 2023-07-19 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-07-17 | 2023-07-19 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-06-15 | 2023-06-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-15 | 2023-06-17 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-06-15 | 2023-06-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-15 | 2023-06-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-15 | 2023-06-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-15 | 2023-06-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-15 | 2023-06-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-15 | 2023-06-17 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-06-15 | 2023-06-17 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-15 | 2023-06-17 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-06-15 | 2023-06-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-06 | 2023-06-10 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-30 | 2023-05-02 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-03-30 | 2023-05-02 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-03-30 | 2023-05-02 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-30 | 2023-05-02 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-12 | 2023-02-10 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-11-10 | 2022-12-23 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-11-10 | 2022-12-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-10 | 2022-12-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-10 | 2022-12-23 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-11-10 | 2022-12-16 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-11-10 | 2022-12-16 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2022-11-10 | 2022-12-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-10 | 2022-12-16 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-09-08 | 2022-09-09 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2022-09-08 | 2022-09-09 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-12 | 2022-07-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-12 | 2022-07-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-12 | 2022-07-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-04-07 | 2022-05-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-05 | 2022-04-12 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-22 | 2022-03-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-17 | 2022-03-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-17 | 2022-03-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-17 | 2022-03-15 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-11-03 | 2021-12-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-11-03 | 2021-12-03 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-16 | 2021-09-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-16 | 2021-09-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-08-16 | 2021-09-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-16 | 2021-09-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-08-16 | 2021-09-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-16 | 2021-09-30 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-08-19 | 2021-09-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-19 | 2021-09-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-08-19 | 2021-09-21 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-08-19 | 2021-09-21 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-08-19 | 2021-09-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-19 | 2021-09-21 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-08-19 | 2021-09-21 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-08-19 | 2021-09-21 | N |
| Post nurse staffing information every day. | Health | 2021-08-19 | 2021-09-21 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-08-19 | 2021-09-21 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-08-19 | 2021-09-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-19 | 2021-09-21 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2021-08-19 | 2021-09-21 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-08-19 | 2021-09-21 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-08-19 | 2021-09-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-21 | 2021-08-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-21 | 2021-08-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-21 | 2021-08-16 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-07-21 | 2021-08-16 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-07-21 | 2021-07-28 | Y |
