Paradigm At The Oak

Penalties

• Feb 20, 2026 — Fine ($12,429)
• Nov 21, 2025 — Fine ($4,410)
• Jan 17, 2025 — Fine ($16,149)
• Nov 7, 2024 — Fine ($70,618)

Inspection findings

1. May 28, 2026 Health · 2 findings
   • Not serious Scope/severity E Complaint

     F0679 Quality of Life and Care Deficiencies

     Provide activities to meet all resident's needs.

     Corrected Jun 19, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jun 19, 2026 · CMS health inspection

2. Apr 2, 2026 Health · 16 findings
   • Not serious Scope/severity D

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Apr 16, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Apr 3, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0577 Resident Rights Deficiencies

     Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

     Corrected Apr 16, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0584 Resident Rights Deficiencies

     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.

     Corrected Apr 16, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0644 Resident Assessment and Care Planning Deficiencies

     Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

     Corrected Apr 16, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Apr 16, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Apr 16, 2026 · CMS health inspection

   • Not serious Scope/severity C

     F0912 Environmental Deficiencies

     Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

     Corrected Apr 16, 2026 · CMS health inspection

   • Not serious Scope/severity D

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Jun 17, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jun 17, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Jun 17, 2026 · CMS fire safety

   • Not serious Scope/severity C

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     CMS fire safety

   • Not serious Scope/severity E

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Jun 17, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0901 Electrical Deficiencies

     Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.

     Corrected Jun 17, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Jun 17, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Jun 17, 2026 · CMS fire safety

3. Mar 5, 2026 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0584 Resident Rights Deficiencies

     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.

     Corrected Apr 2, 2026 · CMS health inspection

4. Feb 20, 2026 Health · 5 findings
   • Serious Scope/severity J Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Feb 11, 2026 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected Feb 11, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Feb 11, 2026 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Feb 11, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Apr 2, 2026 · CMS health inspection

5. Dec 29, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Dec 31, 2025 · CMS health inspection

6. Nov 21, 2025 Health · 5 findings
   • Not serious Scope/severity D Complaint

     F0627 Resident Rights Deficiencies

     Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

     Corrected Nov 22, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0655 Resident Assessment and Care Planning Deficiencies

     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

     Corrected Nov 22, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Nov 22, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0804 Nutrition and Dietary Deficiencies

     Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

     Corrected Nov 22, 2025 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0925 Environmental Deficiencies

     Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

     Corrected Nov 22, 2025 · CMS health inspection

7. Jul 10, 2025 Health · 2 findings
   • Not serious Scope/severity E Complaint

     F0584 Resident Rights Deficiencies

     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.

     Corrected Jul 15, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0921 Environmental Deficiencies

     Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

     Corrected Jul 15, 2025 · CMS health inspection

8. Jun 4, 2025 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Jun 5, 2025 · CMS health inspection

9. Mar 31, 2025 Health · 2 findings
   • Not serious Scope/severity E Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Apr 30, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Apr 30, 2025 · CMS health inspection

10. Jan 28, 2025 Fire Safety · 21 findings
    • Not serious Scope/severity F

      E0001 Emergency Preparedness Deficiencies

      Establish an Emergency Preparedness Program (EP).

      Corrected Apr 16, 2025 · CMS fire safety

    • Not serious Scope/severity E

      F0584 Resident Rights Deficiencies

      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.

      Corrected Feb 28, 2025 · CMS health inspection

    • Not serious Scope/severity D

      F0656 Resident Assessment and Care Planning Deficiencies

      Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

      Corrected Feb 28, 2025 · CMS health inspection

    • Not serious Scope/severity E

      F0657 Resident Assessment and Care Planning Deficiencies

      Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

      Corrected Feb 28, 2025 · CMS health inspection

    • Not serious Scope/severity D

      F0677 Quality of Life and Care Deficiencies

      Provide care and assistance to perform activities of daily living for any resident who is unable.

      Corrected Feb 28, 2025 · CMS health inspection

    • Not serious Scope/severity E

      F0679 Quality of Life and Care Deficiencies

      Provide activities to meet all resident's needs.

      Corrected Feb 28, 2025 · CMS health inspection

    • Not serious Scope/severity D

      F0686 Quality of Life and Care Deficiencies

      Provide appropriate pressure ulcer care and prevent new ulcers from developing.

      Corrected Feb 28, 2025 · CMS health inspection

    • Not serious Scope/severity D

      F0688 Quality of Life and Care Deficiencies

      Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

      Corrected Feb 28, 2025 · CMS health inspection

    • Not serious Scope/severity D

      F0690 Quality of Life and Care Deficiencies

      Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

      Corrected Feb 28, 2025 · CMS health inspection

    • Not serious Scope/severity D

      F0695 Quality of Life and Care Deficiencies

      Provide safe and appropriate respiratory care for a resident when needed.

      Corrected Feb 28, 2025 · CMS health inspection

    • Not serious Scope/severity D

      F0757 Pharmacy Service Deficiencies

      Ensure each resident’s drug regimen must be free from unnecessary drugs.

      Corrected Feb 28, 2025 · CMS health inspection

    • Not serious Scope/severity E

      F0759 Pharmacy Service Deficiencies

      Ensure medication error rates are not 5 percent or greater.

      Corrected Feb 28, 2025 · CMS health inspection

    • Not serious Scope/severity E

      F0812 Nutrition and Dietary Deficiencies

      Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

      Corrected Feb 28, 2025 · CMS health inspection

    • Not serious Scope/severity E

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Feb 28, 2025 · CMS health inspection

    • Not serious Scope/severity D

      F0881 Infection Control Deficiencies

      Implement a program that monitors antibiotic use.

      Corrected Feb 28, 2025 · CMS health inspection

    • Not serious Scope/severity B

      F0912 Environmental Deficiencies

      Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

      Corrected Feb 28, 2025 · CMS health inspection

    • Not serious Scope/severity D

      F0919 Environmental Deficiencies

      Make sure that a working call system is available in each resident's bathroom and bathing area.

      Corrected Feb 28, 2025 · CMS health inspection

    • Not serious Scope/severity E

      K0353 Smoke Deficiencies

      Inspect, test, and maintain automatic sprinkler systems.

      Corrected Apr 24, 2025 · CMS fire safety

    • Not serious Scope/severity D

      K0374 Smoke Deficiencies

      Install smoke barrier doors that can resist smoke for at least 20 minutes.

      Corrected Apr 24, 2025 · CMS fire safety

    • Not serious Scope/severity B

      K0521 Services Deficiencies

      Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

      CMS fire safety

    • Not serious Scope/severity E

      K0712 Miscellaneous Deficiencies

      Have simulated fire drills held at unexpected times.

      Corrected Apr 16, 2025 · CMS fire safety

11. Jan 17, 2025 Health · 1 finding
    • Serious Scope/severity K Complaint

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Jan 1, 2025 · CMS health inspection

12. Nov 7, 2024 Health · 7 findings
    • Not serious Scope/severity E Complaint

      F0550 Resident Rights Deficiencies

      Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

      Corrected Dec 6, 2024 · CMS health inspection

    • Serious Scope/severity G Complaint

      F0584 Resident Rights Deficiencies

      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.

      Corrected Dec 6, 2024 · CMS health inspection

    • Serious Scope/severity J Complaint

      F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

      Corrected Dec 6, 2024 · CMS health inspection

    • Serious Scope/severity J Complaint

      F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Develop and implement policies and procedures to prevent abuse, neglect, and theft.

      Corrected Dec 6, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

      Corrected Dec 6, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0804 Nutrition and Dietary Deficiencies

      Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

      Corrected Dec 6, 2024 · CMS health inspection

    • Serious Scope/severity J Complaint

      F0835 Administration Deficiencies

      Administer the facility in a manner that enables it to use its resources effectively and efficiently.

      Corrected Dec 6, 2024 · CMS health inspection

13. Jun 12, 2024 Health · 1 finding
    • Not serious Scope/severity D Complaint

      F0755 Pharmacy Service Deficiencies

      Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

      Corrected Jun 26, 2024 · CMS health inspection

14. Nov 9, 2023 Health · 9 findings
    • Not serious Scope/severity D

      F0550 Resident Rights Deficiencies

      Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

      Corrected Dec 9, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0584 Resident Rights Deficiencies

      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.

      Corrected Dec 9, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0641 Resident Assessment and Care Planning Deficiencies

      Ensure each resident receives an accurate assessment.

      Corrected Dec 9, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0645 Resident Assessment and Care Planning Deficiencies

      PASARR screening for Mental disorders or Intellectual Disabilities

      Corrected Dec 9, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0699 Quality of Life and Care Deficiencies

      Provide care or services that was trauma informed and/or culturally competent.

      Corrected Dec 9, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0810 Nutrition and Dietary Deficiencies

      Provide special eating equipment and utensils for residents who need them and appropriate assistance.

      Corrected Dec 9, 2023 · CMS health inspection

    • Not serious Scope/severity F

      F0812 Nutrition and Dietary Deficiencies

      Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

      Corrected Dec 9, 2023 · CMS health inspection

    • Not serious Scope/severity B

      F0912 Environmental Deficiencies

      Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

      Corrected Dec 9, 2023 · CMS health inspection

    • Not serious Scope/severity B

      K0521 Services Deficiencies

      Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

      Corrected Dec 9, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• FREUDENBERGER, JOSEPH — corporate officer, NOT APPLICABLE, since 01/01/2023
• SHKOP, AHARON — operational/managerial control, NOT APPLICABLE, since 01/01/2023
• OAKBEND MEDICAL CENTER — 5% or greater direct ownership interest, 100%, since 01/01/2023
• SCHULENBURG NURSING & REHABILITATION LLC — operational/managerial control, NOT APPLICABLE, since 01/01/2023