The Administrator at Paradigm at the Oak told inspectors she thought Resident #2 was "delusional because he said it was a possum and Resident #2 had UTIs." She said the facility's medical director claimed the resident "made stuff up."
Staff attitudes shifted on September 19, 2025, when the charge nurse called the Administrator to report that an agency nurse had seen a rat running through Resident #2's room during the night shift.
The facility's Director of Nursing acknowledged during interviews that rodents posed serious risks to residents who cannot move. He told inspectors that "the negative effect of a rodent in a resident's room was the possibility of being bitten by the rodent and skin infection."
Resident #3, another immobile patient, had rat droppings discovered in his room. The Director of Nursing said this resident "should have been moved as soon as it was confirmed there were rat droppings in his room."
Instead, the Administrator provided Resident #3 with a plastic container for his food after the Director of Nursing explained that mice might eat food stored in the room.
The Administrator and medical director had previously investigated Resident #2's room with a flashlight but found only a gap in the floorboard, which the medical director filled with foam.
A former employee who worked at the facility told inspectors that pest problems contributed to her decision to leave. She said she had reported the issue to the administrator, medical director, and charge nurse during her previous employment.
The Director of Nursing confirmed that bugs were present throughout the facility and represented an infection control problem. He told inspectors that roaches "could be an infection control issue because they represented a dirty environment" and could cause "skin abrasions and bites."
When asked about infection control risks, the Administrator said she "did not know if having rodents and bugs in the facility was an infection control issue."
She defended the facility's pest problems by comparing them to private homes. The Administrator told inspectors that nursing homes were "supposed to have a homelike environment and people who do not live at nursing facilities have bugs and rodents even though they do not want to."
The facility's own pest control policy, dated June 2024, requires staff to "implement measures to prevent, monitor, and address pest activity in a manner that does not compromise resident safety, infection control, or environmental standards."
Federal inspectors found the facility violated infection prevention and control requirements that affect multiple residents.
The Administrator acknowledged she had "not seen live bugs in the facility" personally, despite staff reports and the Director of Nursing's confirmation of ongoing pest problems.
For Resident #3, who cannot move independently, the presence of rodents and their droppings created particular vulnerability. The Director of Nursing explained that immobile residents face greater difficulty when rodents are present in their living space.
The night agency nurse's sighting of the rat validated weeks of concerns that staff had attributed to a resident's mental state rather than investigating thoroughly.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Paradigm At the Oak from 2025-11-21 including all violations, facility responses, and corrective action plans.