Paradigm at Woodwind Lakes: DNR Ignored, Immediate Jeopardy - TX
Federal inspectors determined that the facility had no system in place to catch discrepancies in residents' advance directives at the time of admission, and that the failure rose to the level of immediate jeopardy, the most serious finding available under federal nursing home oversight. The inspection was conducted April 28, 2026, following a complaint.
The resident is identified in inspection records only as Resident 1. What happened to them, exactly, is not something the facility's plan of correction dwells on. The paperwork focuses almost entirely on what comes next. But the sequence of events is not in dispute: a resident arrived at the facility with a documented wish not to be resuscitated, that wish was not properly verified and reconciled with the resident's active code status, and at some point emergency interventions were performed that the resident had specifically refused in advance.
The facility's own policy, titled "Texas OOH DNR," revised in May 2025, states that the facility will respect residents' rights to execute a valid Out-of-Hospital Do Not Resuscitate order and will comply with all applicable state laws regarding those orders. The policy existed. The system to carry it out did not.
Inspectors notified the administrator, the director of nursing, a regional clinical nurse, and the director of operations of the immediate jeopardy finding at 2:22 in the afternoon. The administrator was handed an immediate jeopardy template and asked to produce a plan to remove the jeopardy. That plan was accepted the same evening at 9:02 PM, roughly seven hours later.
The corrective steps described in the plan reveal how basic the failure was. The administrator and director of nursing had to notify the medical director of the immediate jeopardy finding during an emergency quality meeting. Resident 1's code status was corrected that same day, after staff went directly to the resident's power of attorney to confirm what the resident actually wanted, and then notified the physician. The correction should have happened at admission.
A regional nurse consultant came in to educate the administrator, the social worker, and the director of nursing on how to verify advance directives when a resident arrives, and how to make sure emergency procedures match whatever code status is documented. That this education was necessary at all, for people in those roles, at a facility with a written DNR policy already on the books, is itself a finding.
Licensed nursing staff then received education on CPR policy, DNR policy, and the requirement to verify code status at admission. The facility said newly hired staff would not be permitted to provide direct resident care until completing the same training.
Before any of that was finished, the social worker and the MDS coordinator conducted a full audit of every current resident's code status, checking whether the documentation was accurate and consistent across medical records and physician orders. They found one additional resident whose DNR had not been signed by a physician. That was corrected immediately, with the power of attorney contacted to verify the resident's wishes.
Two residents, then. One who received emergency interventions against their documented wishes, and one whose DNR existed in the record but lacked a physician's signature, meaning it could not have been legally honored in an emergency.
The facility's plan going forward centers on a daily clinical morning meeting where new admissions are reviewed by an interdisciplinary team. The team is supposed to verify code status, confirm that physician orders reflect that status, ensure that consent from the resident or their legal representative is documented, and check that nursing documentation confirms the verification. Any changes to a resident's code status are supposed to be reviewed the same way.
The director of nursing and unit managers are assigned to conduct daily audits on new admissions Monday through Friday. On weekends, a supervisor covers admissions occurring on Saturdays and Sundays. This is to continue for two weeks, then randomly after that. Audit findings are to be reviewed by the director of nursing and the administrator and discussed in quality meetings monthly for three months.
What the plan does not include is any revision to the facility's clinical admission checklist, which inspectors noted had no changes added. The facility's CPR and DNR policies were reviewed by the administrator and also left unchanged. The conclusion reached was that no revisions were required.
That conclusion is worth sitting with. A resident arrived at this facility with a valid do-not-resuscitate order. Staff did not catch that the code status in the record did not match that order. Emergency interventions were performed. Inspectors found an immediate jeopardy. The facility reviewed its policies and decided the policies were fine.
The legal framework governing this situation is not ambiguous. Under federal nursing home regulations, a legal representative's decisions are treated as the resident's own decisions, to the extent required by a court order or applicable law, or as delegated by the resident. The facility cannot extend rights to a legal representative that weren't delegated, but it also cannot override the rights that were. A power of attorney who has been given authority over medical decisions has the right to execute a do-not-resuscitate order on a resident's behalf. That order carries legal weight. It is not a preference. It is a directive.
An out-of-hospital DNR in Texas is a specific legal document. It exists precisely because people want their wishes honored outside of a hospital setting, including in nursing facilities, including during emergencies when there is no time for a conversation. The entire point of the document is that staff do not have to stop and call someone. They look at the order, they see it is valid, and they do not resuscitate. The system Paradigm at Woodwind Lakes had in place failed at the first moment it was tested.
The facility's plan of removal was accepted. The immediate jeopardy was lifted. Resident 1's code status now reflects their verified wishes, according to the facility's own documentation.
What Resident 1 experienced in the time between their admission and the correction, what it meant to them to have an emergency response performed on their body that they had taken legal steps to refuse, is not recorded in the inspection documents. The plan of correction does not address it. The policy review does not mention it. The audit findings, to be discussed in monthly quality meetings over the next three months, will measure whether new admissions are being processed correctly going forward.
Resident 1 is not a metric in those audits. They are the reason the audits exist.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Paradigm At Woodwind Lakes from 2026-04-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Paradigm at Woodwind Lakes in Houston, TX was cited for immediate jeopardy violations during a health inspection on April 28, 2026.
The inspection was conducted April 28, 2026, following a complaint.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.