Paradigm Northwest
Inspection Findings
F-Tag F0580
F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
were educated. During interviews on 8/16/25 from 2:00 pm - 4:45 pm, nurses from the 6am-6pm and 6pm-6am shift were asked to review what was covered during their in-services. All staff stated that if a resident was experiencing a change in condition, the protocol would be to first assess the resident and if there was a deviation from their baseline, their NP or MD should be notified immediately. If the resident has interventions in place, nurses were to follow them or follow the orders given by the NP/MD. If the NP/MD is not available, 911 should be called so that the resident can receive a higher level of care. It was verbalized that the chain in notification would be that the NP would be notified first and if there was no answer, an attempt would be made to the MD, and the immediate scalation would be to call 911 and the ADM. All nurses should continue providing care until EMS arrives. Review of the Facility's QAPI Agenda, dated 8/15/25, reflected that the MD had reviewed and agreed with the plan. MD was interviewed and stated that
a QAPI was held and the team developed a plan to address the issues of the IJs. LVN A was interviewed on 8/16/25 at 2:40 pm. She stated that she was in-serviced on fall management and escalation provider protocol. She said that if a resident has a fall, she was to contact the NP and MD, and if they didn't answer,
she must call the administrator or EMS right away. The ADM and DON were notified on 8/16/25 6:05 pm that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.
Event ID:
Facility ID:
If continuation sheet
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
08/18/2025
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-Tag F0684
F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Review of an in-service titled QAPI 8/15/25: Notification of Change and Quality of Care documented that all nursing staff had been educated on physician escalation notification, all unwitnessed or witnessed falls with
a strike to head should be sent out immediately, and the physician or extending physician should be notified immediately. Attendees including the ADM, DON, and Unit Managers. Review of the in-services dated 8/15/25 titled Education Change of Condition, Physician Escalation Protocol for Provider Notification, and Fall Management displayed that all nursing staff were educated. During interviews on 8/16/25 from 2:00 pm - 4:45 pm, nurses from the 6am-6pm and 6pm-6am shift were asked to review what was covered during their in-services. All staff stated that if a resident was experiencing a change in condition, the protocol would be to first assess the resident and if there was a deviation from their baseline, their NP or MD should be notified immediately. If the resident has interventions in place, nurses were to follow them or follow the orders given by the NP/MD. If the NP/MD is not available, 911 should be called so that the resident can receive a higher level of care. It was verbalized that the chain in notification would be that the NP would be notified first and if there was no answer, an attempt would be made to the MD, and the immediate scalation would be to call 911 and the ADM. All nurses should continue providing care until EMS arrives. Review of
the Facility's QAPI Agenda, dated 8/15/25, reflected that the MD had reviewed and agreed with the plan.
MD was interviewed and stated that a QAPI was held and the team developed a plan to address the issues of the IJs. LVN A was interviewed on 8/16/25 at 2:40 pm. She stated that she was in-serviced on fall management and escalation provider protocol. She said that if a resident has a fall, she was to contact the NP and MD, and if they didn't answer, she must call the administrator or EMS right away. The ADM and DON were notified on 8/16/25 6:05 pm that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.
Event ID:
Facility ID:
If continuation sheet
Paradigm Northwest in Houston, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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.