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Complaint Investigation

Paradigm At The Pines

September 10, 2025 · Silsbee, TX · 705 Hwy 418 W
Citations 6
CMS Rating 2/5
Beds 90
Provider ID 675391
Healthcare Facility
Paradigm At The Pines
Silsbee, TX  ·  View full profile →
Inspection Summary

Paradigm at The Pines in SILSBEE, TX — inspection on September 10, 2025.

Found 6 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0600
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Potential for More Than Minimal Harm

he/she should be contacted regardless of the time of day and made known of the event.

The Administrator, Director of Nursing, or his/her will notify corporate director of clinical services and chief operating officer of any allegation or event concerning abuse, neglect, and/or exploitation.

The Administrator, Director of Nursing, or his/her designee shall report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required and take all necessary corrective actions depending on the results of the investigation.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Paradigm at the Pines

705 Hwy 418 W Silsbee, TX 77656

SUMMARY STATEMENT OF DEFICIENCIES

Record review of the facility's policy Abuse, Neglect, Exploitation Prevention Policy and Procedure, date revised 09/10/2020, indicated Definitions: .Abuse is defined as the willful infliction of injury.

Physical Abuse includes hitting, slapping, pinching and/or kicking.Reporting 1. It is the responsibility of all individuals who witness, or have knowledge of, an event regarding the abuse, neglect, and/or exploitation of any resident, regardless of the length of time between the actual event and his/her coming to knowledge of it, to immediately report it to the Administrator and/or Director of Nursing. If the Administrator or Director of Nursing is not present in the facility at the time, he/she should be contacted regardless of the time of day and made known of the event.

The Administrator, Director of Nursing, or his/her will notify corporate director of clinical services and chief operating officer of any allegation or event concerning abuse, neglect, and/or exploitation.

The Administrator, Director of Nursing, or his/her designee shall report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required and take all necessary corrective actions depending on the results of the investigation.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Paradigm at the Pines

705 Hwy 418 W Silsbee, TX 77656

SUMMARY STATEMENT OF DEFICIENCIES

leading up the alleged incident. 20.

The facility investigation will be documented on the required state investigation form. 21.

The administrator will provide the facility's completed investigation including witness statements and other supporting documentation to the state survey and certification agency with five (5) working days of the reported incident.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Paradigm at the Pines

705 Hwy 418 W Silsbee, TX 77656

SUMMARY STATEMENT OF DEFICIENCIES

assessment will be completed according to established procedures.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Paradigm at the Pines

705 Hwy 418 W Silsbee, TX 77656

SUMMARY STATEMENT OF DEFICIENCIES

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During an interview on 09/09/25 at 02:10 p.m. LVN E said he had received in-service and had participated in elopement drills they had conducted several times after the elopement.

During an interview on 09/09/25 at 03:30 p.m. the UM said in-service and elopement drills had been received from 03/23/25 through 03/27/25.

During an interview on 09/09/25 at 06:00 p.m.:* CNA D said she was the receptionist at the time of the elopement but had received in-service and participated in elopement drills several times after the elopement.* CNA G said she received elopement training while she was in the CNA class at the facility.* CNA H and CNA J said they received elopement training when they were hired by the facility.

During interviews on 09/10/25:* at 10:20 a.m. CNA N said she had received in-service and participated in elopement drills several times after the elopement.* at 10:25 a.m. CNA O said she had received in-service and participated in elopement drills several times after the elopement.* at 10:28 a.m. CNA R said she had received in-service and participated in elopement drills several times after the elopement.

Record review of the Elopement policy revised 05/2024 indicated: Policy:The Facility will engage in active elopement prevention measures to mitigate the occurrence of elopement incidents.

The Facility will deploy a prompt investigation and search if a resident is considered missing.Elopement Mitigation StrategiesThe Facility will implement the following mitigation strategies: Appropriateness of resident placement within the facility upon a::Jmission and during their stay.

Completion of routine elopement risk assessments.

Providing the resident with appropriate supervision.

Completing environmental modifications as needed.

Ensuring the resident's care plan is up to date.

Conducting routine elopement drills.

Having a resident photo in the electronic health record.

Providing education for families, visitors, and volunteers.

Conducting routine alarm checks/inspections.

Initiate a manual monitoring system during power failure. On 09/09/25 at 05:40 p.m., the Administrator was informed of the Immediate Jeopardy.

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 noncompliance before survey began.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Paradigm at the Pines

705 Hwy 418 W Silsbee, TX 77656

SUMMARY STATEMENT OF DEFICIENCIES

to the resident.

She said not having the Inventory Sheet for a narcotic could lead to drug diversion.

During an interview on 09/09/25 at 04:25 p.m. the Administrator said she expected staff to follow policy regarding narcotic medications to prevent drug diversions and ensure residents receive their medication.

Attempts were made to contact LVN X but recording indicated the caller was not taking calls.

Attempts were made to contact RN Y and a message was left with no return call.

Record review of the Narcotic Count policy revised 11/22 indicated the following: Policy: It is the policy of this facility to mitigate the risk of drug diversion by developing, implementing, and maintaining a narcotic count process.

Procedures: The Narcotic Count and Inventory: 1.

Controlled drugs will be counted every eight (8) - or twelve (12) -hour shift by authorized staff reporting on duty with the authorized staff reporting off duty.2.

The inventory of controlled substances/drugs will be recorded on the Narcotic Records and signed for correctness of count.Process:1.

At the end of every eight (8) - or twelve (12) -hour shift the authorized staff member reporting on duty and the authorized staff member reporting off duty meet at the designated medication cart or storage area to count controlled substances/drugs.2.

The off-going authorized staff member reads down the controlled substance/drug Inventory Sheet one drug at a time.3.

The oncoming authorized staff member counts the number of remaining controlled substance/drug and announces that number out loud.4.

The off going authorized staff member checks this number against the Inventory Sheet.

The remaining number is carried over to the controlled substance/drug Inventory Sheet for the new shift.5.

Steps two (2) through four (4) are repeated for each controlled substance/drug in the inventory.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SILSBEE, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Paradigm at The Pines or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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