Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Paradigm At The Pines during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment and incontinence did not have every episode of incontinence care or checks accurately documented in the electronic medical record. CNA staff reported providing care every two hours but were unable to chart each instance due to recent changes in the EMR system, which limited documentation options. The DON was unaware of the duration of this issue, resulting in incomplete clinical records.
A resident with dementia and a high risk for elopement was left unsupervised when the assigned CNA failed to remain on the secured unit as directed. The resident, who had a history of attempting to leave and expressed a desire to go home, was able to exit the facility by climbing over a fence and was later found at his previous home. Staff interviews and documentation confirmed that the lack of supervision directly led to the resident's elopement.
Multiple residents with severe cognitive and behavioral health conditions were subjected to physical abuse by other residents, including slapping, hair-pulling, punching, and pushing that resulted in a fall. These incidents were witnessed by staff and a contracted lab technician, and occurred despite documented care plans and staff awareness of behavioral risks.
The facility did not thoroughly investigate multiple incidents of resident-to-resident physical altercations, failing to document interviews with other residents to ensure their safety and wellbeing as required by policy. Staff interviews revealed that safe surveys were not consistently conducted or recorded, especially when the social worker was unavailable, despite the residents involved having significant cognitive and physical impairments.
Two residents with severe cognitive impairment were involved in incidents of resident-to-resident aggression, but their care plans were not updated by the interdisciplinary team to reflect these events or add new interventions. Despite staff awareness of the incidents and facility policy requiring care plan revisions after changes in status, the necessary updates were not made, leaving care plans outdated.
A resident with severe cognitive impairment was punched in the arm by another resident with dementia and psychosis. The incident was witnessed by an LVN, reported internally, and documented, but was not reported to the state agency within the required two-hour timeframe as mandated by facility policy. Both the DON and administrator later acknowledged that the event met the criteria for reportable physical abuse, but no report was made to the state agency.
A resident prescribed hydrocodone/acetaminophen for pain management did not have her controlled medication properly counted or documented during shift changes. Nursing staff failed to consistently perform narcotic counts and maintain required inventory sheets, leading to discrepancies in pill counts and missing medication. The facility's policy for shift-to-shift controlled drug reconciliation was not followed, resulting in incomplete records and an inability to accurately account for all controlled substances.
The facility failed to provide palatable and nutritious meals, as residents complained about the taste and edibility of the food. A test tray revealed a chicken wrap that was soggy and unappetizing, and a potato salad with an overpowering garlic flavor. The Dietary Manager did not follow recipes, substituting ingredients and not tasting the food. The Administrator noted that this could result in residents not receiving a balanced diet.
The facility failed to maintain sanitary conditions in its kitchen by not labeling or properly closing food items in the freezers. Observations revealed that several opened bags of food, such as okra, waffles, corn, squash, and riblets, were not labeled with product or expiration dates and were exposed to air. The Dietary Manager and Administrator acknowledged the importance of proper labeling and storage to prevent serving expired foods to residents.
The facility failed to accurately complete MDS assessments for two residents receiving anticoagulant medications. One resident with a history of embolism and thrombosis was prescribed Eliquis, and another with venous thrombosis and embolism was prescribed apixaban. Despite receiving these medications, their MDS assessments did not reflect this, due to oversight by the MDS nurse. Interviews revealed a lack of backup for accuracy checks, leading to the oversight.
A facility failed to include the anticoagulant medication Eliquis in a resident's care plan, despite its prescription and administration for managing embolism and thrombosis. The omission was identified through interviews with staff, who acknowledged the lack of a backup system to verify care plan accuracy. The facility's policy mandates comprehensive care plans, which was not followed in this instance.
A facility failed to remove an expired insulin pen from a medication cart, which was used for a resident with severe cognitive impairment and diabetes. The insulin pen, opened 60 days past its expiration, was found during a cart review. Despite daily checks by nurses and monthly checks by a pharmacy consultant, the expired pen was overlooked, potentially affecting the medication's effectiveness.
The facility failed to follow the menu and recipes for a lunch meal, leading to deviations in the chicken wrap and potato salad served. The Dietary Manager did not adhere to the recipes due to missing ingredients and personal preferences, resulting in potential nutritional inadequacies. The Administrator expected the recipes to be followed and missing ingredients to be reported for purchase.
A resident with a history of sexual behaviors inappropriately touched another resident in a dining area, despite staff awareness and previous interventions. The incident was witnessed by two other residents who alerted staff, leading to immediate separation. The facility's failure to manage the resident's behaviors and protect others highlights a deficiency in ensuring resident safety.
Incomplete Documentation of Incontinence Care Due to EMR Limitations
Penalty
Summary
The facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards for two residents who required total care for toileting hygiene due to severe cognitive impairment and incontinence. Record reviews showed that both residents' care plans required routine rounding and incontinence care, but the CNA flow sheets for November 2025 did not accurately document each instance of incontinence care or checks. Documentation was incomplete, with no indication that incontinence care was provided as required, despite staff statements that care was given every two hours. Interviews with staff revealed that recent updates to the electronic medical record system had removed the option for CNAs to chart each episode of incontinence care or checks, limiting documentation to one or two times per shift. The DON confirmed that she was unaware of how long this documentation issue had persisted and acknowledged responsibility for ensuring complete and accurate medical records. The facility's policy allowed for electronic medical records in lieu of paper records, but the system's limitations led to incomplete documentation of care provided.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident, assessed as high risk for elopement due to diagnoses including dementia, hypertension, type 2 diabetes, anxiety, and depression, was left unsupervised on a secured memory care unit. The resident had a history of restlessness, attempts to leave the unit, and expressed a desire to go home, as documented in multiple nurse notes. The care plan and risk assessments identified the need for frequent checks and supervision, especially during high-risk times. On the day of the incident, the staff member assigned to supervise the secured unit left the area unattended. The charge nurse had instructed a CNA to relieve the current staff member for a lunch break, but the CNA failed to go to the unit as directed and was observed elsewhere in the facility. During this period, the resident eloped from the secured unit, using a chair and trash can to climb over the courtyard fence. The resident was later found at his previous home address, approximately one mile from the facility, and was returned without injury. Interviews with staff confirmed that the CNA assigned to the unit was not present at the time of the elopement, and the absence of supervision directly contributed to the resident's ability to leave the facility. Documentation and staff statements indicated that the resident's risk for elopement was well known, and the failure to provide adequate supervision resulted in the resident's unsupervised departure from the secured unit.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from physical abuse by other residents, as evidenced by several documented incidents. One resident with Huntington's disease and severe cognitive impairment was slapped on the neck and had her hair pulled by another resident with alcohol-induced dementia and psychosis. This incident was witnessed by an LVN, who observed the aggressor hitting the resident in the face and pulling her hair while both were in wheelchairs in the hallway. The same resident was later punched in the arm by the same aggressor during another incident, which was also witnessed by staff. In both cases, the residents were separated, and the aggressor was returned to his room, but the incidents still occurred despite staff awareness of a history of resident-to-resident incidents between these individuals. Another incident involved a resident with vascular dementia pushing a resident with Alzheimer's disease and PTSD, causing the latter to fall in the dining room. This event was witnessed by a contracted lab technician, who saw the push and subsequent fall. The resident who fell was upset but not injured, and both residents were separated following the incident. The aggressor was placed on 1:1 monitoring, but the altercation had already taken place, indicating a failure to prevent physical abuse between residents. The residents involved in these incidents had significant cognitive and behavioral health diagnoses, including Huntington's disease, bipolar disorder, schizoaffective disorder, alcohol-induced dementia, psychosis, vascular dementia, Alzheimer's disease, and PTSD. Care plans for these residents included interventions such as monitoring for behaviors, redirection, and 1:1 interaction as needed. Despite these interventions being documented, the facility did not prevent the physical altercations, and staff were aware of the potential for such incidents due to the residents' histories and diagnoses.
Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to provide evidence that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for four out of six residents reviewed. Specifically, there were three separate incidents involving resident-to-resident altercations that were not fully investigated according to facility policy and regulatory requirements. In two incidents, one resident was slapped on the neck and later punched on the arm by another resident, and in a third incident, a resident was pushed by another, resulting in a fall. In each case, the facility's investigation did not include documentation that other residents were interviewed to ensure their safety and wellbeing following the allegations. The residents involved had significant cognitive and physical impairments, including diagnoses such as Huntington's disease, bipolar disorder, schizoaffective disorder, dementia, and other mental health conditions. Assessments indicated that these residents had severely to moderately impaired cognition and required varying levels of assistance with daily activities. Despite these vulnerabilities, the facility did not complete or document 'safe surveys' or interviews with other residents who may have been affected or witnessed the incidents, as required by facility policy. Interviews with staff, including the DON, social worker, and administrator, revealed a lack of clarity and follow-through regarding responsibility for conducting and documenting safe surveys after abuse allegations. The DON and administrator acknowledged that the facility's policy required such actions, but stated that these were not completed or documented, particularly when the social worker was unavailable. The facility's own policy outlined the need for comprehensive investigations, including interviews with other residents, but this was not consistently followed or recorded in the cases reviewed.
Failure to Update Care Plans After Resident-to-Resident Aggression
Penalty
Summary
The facility failed to review and revise the comprehensive care plans for two residents after significant incidents of resident-to-resident aggression. For one resident with Huntington's disease, bipolar disorder, major depressive disorder, schizoaffective disorder, and anxiety disorder, the care plan was not updated to reflect incidents where she was the recipient of aggressive behavior from another resident. These incidents included being hit and having her hair pulled, as well as being punched in the arm. Despite assessments and monitoring following these events, the care plan did not document these changes or add new interventions related to the aggression she experienced. Another resident, diagnosed with alcohol-induced dementia, psychosis disorder, COPD, diabetes mellitus, anxiety disorder, and depressive disorder, was involved as the aggressor in the same incidents. His care plan was also not updated to reflect his involvement in the aggressive behaviors, nor were new interventions or strategies documented to address these behaviors. Both residents had severely impaired cognition and required varying levels of assistance with daily activities and mobility, as documented in their assessments. Interviews with staff revealed that incidents and allegations were discussed in morning meetings, and the MDS Coordinator was responsible for updating care plans. However, the care plans for both residents were not revised after the incidents, and the DON acknowledged that she did not verify whether the updates had been made. The facility's policy required care plans to be reviewed and revised after a change in status, but this process was not followed, resulting in care plans that did not reflect the residents' current needs after the incidents.
Failure to Timely Report Alleged Physical Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported to the State Survey Agency within the required timeframe. Specifically, an incident occurred in which one resident, who had a history of Huntington's disease and severely impaired cognition, was punched in the arm by another resident with a diagnosis of alcohol-induced dementia and psychosis disorder. The incident was witnessed by an LVN, who immediately separated the residents and reported the event to the DON, ADON, and the administrator. Resident assessments following the incident revealed no injuries or pain, and the event was documented in the facility's records. Despite the facility's policy defining physical abuse as including hitting and requiring immediate reporting of such incidents, the event was not reported to the state agency within the mandated two-hour window. The DON and administrator were both notified of the incident and conducted an internal investigation. During this process, the resident who was punched denied being hit and described the event as the other resident moving her arm out of his face. Based on this information and after consultation with a corporate nurse, the decision was made not to report the incident as abuse to the state agency. A review of the Texas Unified Licensure Information Portal confirmed that no self-reported incidents regarding allegations of abuse were submitted for the resident involved. Both the DON and administrator acknowledged during interviews that, according to facility policy, the incident should have been reported as an alleged physical abuse event to the state agency within two hours, regardless of the internal investigation's findings. The failure to report the incident as required constituted a deficiency in the facility's abuse reporting procedures.
Failure to Maintain Accurate Controlled Drug Inventory and Shift Counts
Penalty
Summary
The facility failed to establish and maintain an adequate system for the receipt and disposition of controlled drugs, specifically hydrocodone/acetaminophen prescribed to a female resident with a hip fracture and severely impaired cognition. The resident was admitted with an order for hydrocodone 5 mg/acetaminophen 325 mg, and her medication was brought in by her representative. Upon arrival, the medication was counted by two nurses and a count sheet was created, but subsequent handling of the medication was inconsistent and not in accordance with facility policy. During the period under review, nursing staff did not consistently count the narcotic medications during shift changes, and not all narcotics had an associated Inventory Sheet. On one occasion, the hydrocodone/acetaminophen was not counted and lacked an Inventory Sheet. Discrepancies in pill counts were identified, with counts varying between staff and the resident's representative, and a significant number of pills were found to be missing. The MAR indicated fewer pills had been administered than the number missing from the bottle, and the required narcotic sheet for the bottle was missing at the time of the investigation. Interviews with staff revealed that nurses did not always count narcotics together at shift change, and one nurse accepted the narcotic keys without performing the required count. The facility's policy requires controlled drugs to be counted at every shift change by both oncoming and off-going staff, with counts recorded on the Narcotic Records. These procedures were not followed, resulting in an inability to accurately reconcile the controlled drug inventory and maintain proper records.
Failure to Provide Palatable and Nutritious Meals
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. During initial rounds, residents complained about the food tasting bad and being inedible at times. On a specific day, a test tray containing a chicken ranch wrap, potato salad, and pear crisp was observed. The chicken wrap was not properly wrapped and resembled a taco, with soggy breaded meat that did not taste like chicken. The potato salad had an overpowering garlic flavor, which was not part of the original recipe. The Dietary Manager (DM) admitted to not tasting the food during preparation and not following the recipes, citing personal dietary preferences. He used breaded chicken patties instead of the specified chicken due to a delivery issue and substituted canned tomatoes for fresh ones. Additionally, he altered the potato salad recipe by omitting hard-boiled eggs and pickle relish and adding garlic. Residents expressed dissatisfaction with the meal, stating that the chicken wrap and potato salad were unpalatable. The Administrator acknowledged that not following recipes could lead to residents not receiving a nutritionally balanced diet and emphasized the importance of adhering to approved menus and recipes.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, specifically in the storage of food items in the freezers. During an observation, it was noted that several food items in Freezer #1 and Freezer #2 were not labeled with product or expiration dates. These items included opened bags of okra, waffles, corn, squash, and riblets. Additionally, some of these items were not properly closed, leaving them exposed to air, which could lead to freezer burn and potential contamination. The Dietary Manager acknowledged that all opened foods should be labeled with the date opened and properly closed to prevent such issues. The facility's policy on food storage, as well as the 2022 Food Code, requires that frozen foods be stored in moisture-proof wrap or containers that are labeled and dated. The Dietary Manager confirmed that the lack of labeling and proper storage could result in expired foods being served to residents. The Administrator, who supervises the Dietary Manager, also stated that he expected all foods in the kitchen to be stored properly, including labeling and dating, to prevent the risk of serving expired foods to residents.
Inaccurate MDS Assessments for Anticoagulant Use
Penalty
Summary
The facility failed to ensure accurate assessments for two residents regarding their anticoagulant medication use. Resident #5, a female with a history of embolism and thrombosis, was prescribed Eliquis for venous thrombosis. Despite receiving this medication as per her physician's orders and medication administration records, her most recent MDS assessment did not reflect her anticoagulant use. Additionally, her care plans did not indicate the receipt of this medication, although she confirmed during an observation that she was on an anticoagulant. Similarly, Resident #54, a female with a diagnosis of venous thrombosis and embolism, was prescribed apixaban for heart failure. Her medication administration records confirmed the administration of this medication, yet her MDS assessment failed to capture this information. Her care plan did acknowledge the anticoagulant use, but during an observation, she was unable to specify the medication she was receiving. Interviews with the MDS nurse, Regional Reimbursement Director, DON, and Administrator revealed that the MDS assessments were not accurately coded for anticoagulant medication due to oversight. The MDS nurse was responsible for all MDSs and acknowledged the error, noting a lack of backup for accuracy checks. The Regional Reimbursement Director and DON were unaware of the oversight, and the Administrator emphasized the need for 100% compliance in documentation.
Failure to Include Anticoagulant in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically regarding the administration of the anticoagulant medication, Eliquis. The resident, a cognitively intact female, was admitted with a history of embolism and thrombosis and was prescribed Eliquis to manage her condition. Despite receiving the medication as per the physician's orders, the resident's care plan did not reflect the administration of this anticoagulant, nor did the most recent MDS assessment indicate its use. Interviews with facility staff, including the MDS Nurse, Regional Reimbursement Director, DON, and Administrator, revealed that the oversight was due to a lack of double-checking for accuracy in care plans. The MDS Nurse, responsible for care plans, acknowledged the omission and stated that there was no backup system in place to verify the accuracy of care plans. The facility's policy requires the interdisciplinary team to develop a comprehensive care plan for each resident, but this was not adhered to in this case, leading to the deficiency.
Expired Insulin Pen Not Removed from Medication Cart
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not removing an expired insulin pen from a medication cart, which was used for a resident with end-stage renal disease and type 2 diabetes mellitus. The insulin pen, Insulin Glargine yfgn, was opened on 08/03/24 and had expired 60 days prior to the survey, yet it remained in use. This oversight was identified during a review of the medication cart on Hall B and the right side of Hall C, where the pen was found with a label indicating the resident's name and the open date. The resident involved was a male with severe cognitive impairment, as indicated by a BIMS score of 3, and had been receiving insulin injections daily. The resident's care plan required insulin administration as prescribed and monitoring for side effects and effectiveness. Despite these requirements, the expired insulin pen was not removed from the medication cart, potentially compromising the therapeutic effects of the medication. Interviews with the LVN, DON, ADON, and Administrator revealed that the nurses were responsible for checking their medication carts daily for expired medications. The pharmacy consultant conducted monthly checks, and the DON and ADON performed surprise checks quarterly. However, the expired insulin pen was overlooked, and the staff acknowledged that the insulin might not have been as effective due to its prolonged use beyond the recommended time frame.
Failure to Follow Menu and Recipes for Nutritional Adequacy
Penalty
Summary
The facility failed to ensure that the menu was followed for one of the three meals reviewed, specifically the lunch meal on October 1, 2024. During an observation and interview, it was noted that the chicken ranch wrap served did not adhere to the recipe. The wrap was not properly wrapped and resembled a taco, with soggy breaded meat that did not taste like chicken, and canned tomatoes instead of fresh. The potato salad also deviated from the recipe, having a strong garlic flavor and missing key ingredients like hard-boiled eggs and pickle relish. The Dietary Manager (DM) admitted to not following the recipes, citing a lack of ingredients due to a delivery issue and personal dietary preferences as reasons for not tasting the food. The DM acknowledged that not following the recipes could result in residents not receiving dietician-approved meals, potentially decreasing the nutritional value and altering the taste of the food. The facility's Administrator stated that the expectation was for menus and recipes to be followed, and any missing ingredients should have been reported so they could be purchased. The facility's Food Preparation policy emphasizes the importance of using standardized recipes to conserve nutritive value, flavor, and appearance, which was not adhered to in this instance.
Inadequate Protection from Abuse in LTC Facility
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, specifically inappropriate sexual touching, involving two residents. Resident #1, a female with dementia and other cognitive impairments, was inappropriately touched by Resident #2, a male with a history of sexual behaviors and cognitive impairments, in the dining area. This incident was witnessed by two other residents who alerted the staff, leading to the immediate separation of the involved residents. Despite Resident #2's denial of the incident, the observations of the witnesses confirmed the inappropriate behavior. Resident #2 had a documented history of inappropriate sexual behaviors towards staff and other residents, with multiple incidents recorded over several months. These behaviors included inappropriate comments, gestures, and touching, which were often redirected by staff. Despite various interventions, including medication adjustments and psychiatric evaluations, Resident #2's behaviors persisted. The facility's records indicate that Resident #2 had been transferred to a behavioral hospital multiple times due to these ongoing issues. The facility's failure to adequately manage Resident #2's behaviors and protect Resident #1 from abuse highlights a significant deficiency in ensuring resident safety. The incident involving Resident #1 and Resident #2 was reported to the state agency, and the facility's records show that staff were aware of Resident #2's behaviors and had been instructed to monitor him closely. However, the measures in place were insufficient to prevent the incident from occurring, resulting in a breach of the residents' right to be free from abuse.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Silsbee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Silsbee Oaks Health Care Llp | 1.3 mi | — | 9 | 0 |
| Mill Creek | 2.4 mi | — | 7 | 0 |
| Village Creek Rehabilitation And Nursing Center | 6.9 mi | — | 16 | 3 |
| Paradigm At Kountze | 10.1 mi | — | 0 | 0 |
| Jefferson Nursing And Rehabilitation Center | 16.3 mi | — | 0 | 0 |
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