Paradigm Northwest
Paradigm Northwest in Houston, TX — inspection on August 18, 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.
Inspection Findings
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/18/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Paradigm Northwest
17600 Cali Dr Houston, TX 77090
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID: