Paradigm Northwest

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Paradigm Northwest

17600 Cali Dr Houston, TX 77090

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

him, so the revision was missed. In an interview with LVN K on 8/12/2025 at 2:43 PM, he said he worked

the 10:00 PM-6:00 AM shift. He said she was in-serviced on abuse neglect, transferring and have two staff to provide care for residents who were total care with ADLs and could not assist the staff and infection control. In an interview with LVN D on 8/12/2025 at 3:14 PM, she said she worked the 2:00 PM-10:00 PM shift. She said she was in-serviced on abuse neglect, two persons assist with transferring and providing care to residents who were total care with ADLs. She said she also was in-serviced on infection control and dignity. In an interview with LVN H on 8/12/2025 at 3:45 PM, she said she worked the 2 PM-10 PM shift.

She said she was in-serviced on abuse neglect, transferring and always to have two staff to provide care for residents who were total care with ADLs and could not assist the staff. Record review of staff training record revealed they were trained on incontinent, transfer and ensure two staff assisted when incontinent care was being done. Record review of the facility's, undated, policy and procedure on Incident and Accident read in part .Introduction:Ensuring resident safety management, incident response, in a nursing facility requires a structured approach to risk management, incident response and regulatory compliance. Incident vs Accident* Incident: Unexpected or unusual event within the facility that potentially affects resident safety, well-being, or quality of care.* Accident: An unplanned and unforeseen event resulting in harm, injury, or damage to a resident, staff member, visitor or property.Types of incidents and Accidents:Falls: Any unintentional descent to the floor, including assisted falls.Fractures or bodily injury: Any incident resulting in injury requiring medical attention. Record review of the facility's in-services revealed CNA A (received written disciplinary warning and 1:1 education) and nursing staff were educated on 08/06/2025, 08/07/2025 and 8/8/2025 regarding two-person assistance for residents who were total care or if staff were unsure of their mobility status related to incontinent care. Record review of In-Service, dated 08/06/2025, revealed CNA A (CNA A received 1:1 education) and all other nursing staff were educated by the DON regarding demonstrating accessing and utilizing the Kardex on PCC (the facility's computer system). Record review of in-Service, dated 08/06/2025, 08/07/2025 and 08/08/2025 revealed all staff were educated by the DON and Administrator regarding Abuse and Neglect, transferring of resident and 2 person to provide incontinent care for resident. Record review of the facility's Ad hoc Qapi dated 8/7/2025 revealed:Findings: Certified Nursing Assistant performed incontinent care on a resident that required a two-person bed mobility.1.The resident does not currently reside at the facility. He is currently at the local hospital.2. Certified Nursing Assistance was provided one and one education of the Kardex and before providing care to review the Kardex and use appropriate supervision and assistance.3. 100 percent audit was completed by nurse management to ensure all resident Kardex had the mobility and transfer status present.4. Administrator provided educational in-service on incident accident/accident policies and procedures and abuse/neglect and exploitation.5. DON/designee provided education on the Kardex. Kardex Competency skills training check off completed for Certified Nursing Assistant, and nurses. 6. All training and education will be provided before the next shift including PRN staff. All information was reviewed with the Administrator, DON, Unit Manager, Medical Director, during the Ad hoc QAPI meeting on 8/7/2025 to review all findings.7.

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.

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