Paradigm At Woodwind Lakes
Paradigm at Woodwind Lakes in Houston, TX — inspection on April 28, 2026.
Found 2 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.
Inspection Findings
her at the facility.
Family Member #1 said she never received an admission packet, and no one ever
Coordinator said she was responsible for the admission packet, and it was usually completed after
in person and it was usually completed within 48 hours of admission.
The Admissions Coordinator said the admission packet addressed residents wishes, laundry and consent to take pictures.
She said she did not go through the admissions packet with the resident or their RP, and she only emailed the packet after the resident admitted to the facility.
The Admissions Coordinator said she did not have an admissions packet for CR #1, and Family Member #1 (CR #1's POA) never received the admissions packet.
She said Family Member #1 was with CR #1 when she arrived with the resident, but she never received the admissions packet, there were no communications of the resident's rights or anything contained in the packet.
The Admissions Coordinator said she intentionally did not send Family Member #1 the admissions packet because she had to confirm she was the POA, and the executed POA was provided to the facility with admissions documentation that came before and after the resident admitted but she didn't know it was at the time.
The Admissions Coordinator said she had no obligation to communicate the contents of the admissions packet to the resident or their designee.
She said failure to deliver the admissions packet would leave residents and their families unaware of their rights. In an interview on [DATE] at 11:58 AM, the Administrator said the Admissions Packet functioned as a way to make sure residents were aware of any information they needed while they lived at the facility and their rights.
She said the packet contained the residents' rights, advance directive wishes and the resident/designee should be provided the packet before they arrived or at the very least at admission.
The Administrator said failure to deliver or communicate the contents of the admissions packet could leave residents unaware of their rights, and the facility would not know the resident's wishes.
Record review of a blank facility TX admission Packet revealed, the packet included charges, Resident Rights, and polices that included: state resident rights, federal resident rights, smoking policy notification, and the bed-hold policy notification.
The packet contained forms, Resident Preferences, Financial Information, and Acknowledgements: selection of resident preferences, statement of resident rights acknowledgement, notice of privacy practices acknowledgement.
The packet also contained, Clinical and Consent Forms: consent to treatment, consent to photograph, video, and Media Use, Pharmacy Services Agreement, Advance Directive Notice and Acknowledgement.
675085 04/28/2026
Paradigm at Woodwind Lakes 7215 Windfern Rd Houston, TX 77040
financial matters, or receiving notifications.The decisions of a legal representative are treated as the
jeopardy to resident health or resident.
The facility may not extend additional rights to the legal representative that were not safety delegated by the resident, the court, or applicable law.
Record review of the facility policy titled Texas OOH DNR revised 05/2025 revealed, The Facility respects the rights of residents to make
(OOH-DNR) order.
The facility will comply with all applicable state laws regarding OOH-DNR orders.
This was determined to be an Immediate Jeopardy (IJ) on [DATE].
The Administrator, DON, Regional Clinical Nurse and Director of Operations were notified of the IJ on [DATE] at 02:22 PM and the Administrator was provided with the IJ template.
The following Plan of Removal submitted by the facility was accepted on [DATE] at 09:02 PM.
Plan of Removal - F-F578 [DATE]Deficient Practice:The facility failed to have a system in place to clarify discrepancies in residents' advance directives immediately upon admission.Corrective Actions Taken:The Administrator and Director of Nursing (DON) notified the Medical Director of the Immediate Jeopardy on [DATE] during an ad hoc QAPI meeting.Resident #1's code status was immediately corrected on [DATE] to reflect verified wishes following direct confirmation with the POA and physician notification.On [DATE], the Regional Nurse Consultant provided education to the Administrator, Social Worker and DON regarding:Verification of advance directives upon admissionEnsuring emergency procedures align with the resident's code statusThe DON initiated education on [DATE] for licensed nursing staff on:CPR policy and DNR policyVerification of code status upon admission with nursing documentationEnsuring emergency interventions align with resident code statusEducation for newly hired staff will be incorporated into orientation.
Staff will not be allowed to provide direct resident care until training has been completed.Education will be completed on [DATE] .The Social Worker and MDS completed a 100% audit of all current residents' code statuses on [DATE] to ensure accuracy and consistency across medical records and physician's orders. 1 resident was identified with an incomplete DNR not signed by the physician but was immediately corrected and verified by POA.Systemic Changes Implemented:All new admissions will be reviewed during the daily clinical morning meeting with the interdisciplinary team (IDT) to:Verify code statusEnsure accurate and consistent documentation, including:Physician's ordersVerified consent from resident/POANursing documentation of confirmationAll new physician's orders will be reviewed in the clinical morning meeting to ensure:Any changes in code status are verified o Supporting documentation is complete and consistent within the medical record No changes were added to the facility policy.No changes to facility clinical admission checklist were noted or added.Monitoring Plan:The Director of Nursing (DON) and/or Unit Managers will conduct daily audits Monday through Friday on new admission, while the Weekend Supervisor will review admissions occurring on Saturdays and Sundays for a period of two weeks and randomly thereafter to ensure that code status is verified and accurately documented. No changes to the policy were needed.Audit findings from the daily new admission audits will be reviewed by the DON and Administrator and discussed during QAPI meetings monthly x3 months.Any identified issues will result in immediate corrective action and staff re-education.Policy Review:The Administrator reviewed the facility policy on CPR, DNR, and Clinical admission checklist on [DATE]. No revisions were required at this
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.