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Complaint Investigation

Paradigm Northwest

August 12, 2025 · Houston, TX · 17600 Cali Dr
Citations 2
CMS Rating 1/5
Beds 148
Provider ID 455714
Healthcare Facility
Paradigm Northwest
Houston, TX  ·  View full profile →
Inspection Summary

Paradigm Northwest in Houston, TX — inspection on August 12, 2025.

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.

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Inspection Findings

FF0656
Resident Assessment and Care Planning Deficiencies
Potential for More Than Minimal Harm

incontinent bowel. Resident #2 was triggered for cognition, incontinence, pressure sore, activities, dehydration, falls, psychosocial well-being, communication and nutrition.

Record review of Resident #2's care plan, initiated 6/06/2025, revealed the care plan did not address cognition, activities and nutrition. In an interview on 8/12/2025 at 2:18 PM, the DON said they did not have a MDS Coordinator.

She said the corporate nurse was helping them and was doing a 100% audit to ensure all triggered areas on the MDS were captured on the care plan.

She said they were going to try and ensure all triggered areas on the MDS were captured on the care plans to ensure residents care needs were addressed.

Record review of the policy and procedures, dated March 2022, Care Plans, Comprehensive Person-Centered read in part .Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Policy Interpretation and Implementation1.

The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/12/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Paradigm Northwest

17600 Cali Dr Houston, TX 77090

SUMMARY STATEMENT OF DEFICIENCIES

During the morning clinical meeting, accidents and incident will be review daily and at-risk meetings for trends with IDT team members brought to monthly QAPI.

The noncompliance was identified as PNC.

The IJ began on 08/11/2025 and ended on 08/12/2025.

The facility had corrected the noncompliance before the survey began.

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 Houston, 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 Northwest or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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