Paradigm At Woodwind Lakes

arrived at the facility within minutes.On 3/22/26 at 3:42 PM, the Administrator said Resident #3

She said residents in memory care were at increased risk for falls and injury without supervision.

She

each other on passing on supervision responsibilities to keep the residents safe.

She said the incident might have been preventable if appropriate supervision was maintained.

She said staff reported that once Resident #3 was found on the floor, the nurse assessed Resident #3 and notifications were made, and once the hematoma was identified, 911 was called and Resident #3 was sent out.

She said the staff acted appropriately once the change in condition was identified.On 3/27/26 at 12:28 PM, the DNP said she was notified of Resident #3's unwitnessed fall and was informed Resident #3's vital signs were within normal limits.

She said she instructed staff to monitor Resident #3 and notify her of any changes in condition.

She said she was later notified that Resident #3 developed a hematoma and was being sent out to the hospital.

She said the discoloration observed was related to the hematoma and consistent with the injury.

She said the facility staff acted appropriately in notifying her and sending Resident #3 out once the hematoma was identified.

She said she was not willing to provide a statement regarding potential risk and did not provide hypothetical risk statements.

Review of the facility's policy titled Dementia Care indicated Resident who display symptoms or are diagnosed with dementia should receive the appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being.The facility provides treatment and services that include, but are not limited to:.necessary person-centered care and services that reflect the resident's goals.while maximizing their dignity, autonomy, privacy, socialization, independence choice, and safety.Staff providing care to residents with dementia.will have competencies and skills to support the resident with dementia through the implementation individualized approaches to care that are directed toward understanding, preventing, relieving, and/or accommodating a resident's distress of loss of abilities.

Review of the facility's policy titled Fall Management revised 07/2025 indicated The facility will provide a safe environment for all residents by implementing a fall management program.

The program includes.individualized care plans.Develop an individualized fall prevention plan for each resident identified at risk.

Examples of interventions: Environmental modifications.non-slip footwear; supervision during high risk activities e.g.ambulation.

Review of the facility's policy titled Standards of Care revised 10/2023 indicated All care provided will comply with current guidelines, best practices, and Federal/State regulations.Safety measures will be in place to prevent accidents and injuries, including fall preventions strategies.All staff members are responsible for adhering this policy and for providing care that meets these standards.

The Administrator will oversee the implementation and compliance with this policy.

675085 03/27/2026

Paradigm at Woodwind Lakes 7215 Windfern Rd Houston, TX 77040

worsen the slit. He stated sediment could block the foley and cause leakage, leading to skin

area was normal in color with a slit and she did not observe blood because staff had cleaned the area.

sediment and noted a history of UTIs.

She stated sediment can be normal but must be reported.

She stated only the bag was changed.

She stated the NP did not express concern, but was unsure of timing.

She stated the meatus could bleed due to foley use and contractures.

She stated the balloon could leak or deflate and prolonged moisture could cause breakdown.

During an interview on 03/26/26 at 4:18 p.m., the Corporate Nurse stated a deflated balloon or sediment could cause leakage.

She stated LVN M should notify the physician if clogging occurred.

She was not aware of the worsening slit.

She stated the physician previously indicated the slit was due to chronic foley use.

She stated irritation could occur if the foley was pulled, although a stat lock was present.

Record review of the facility's policy on catheter care revised 02/2024 stated in part: to ensure proper hygiene, minimize infection risk, and maintain resident comfort during catheter care.

Exposure of Catheter Site: Male Resident: If uncircumcised, retract the foreskin and hold the penis just below the glans.

Maintain this position throughout the procedure.