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Complaint Investigation

Paradigm At Faith Memorial

July 29, 2024 · Pasadena, TX · 811 Garner Rd
Citations 2
CMS Rating 3/5
Beds 112
Provider ID 675321
Healthcare Facility
Paradigm At Faith Memorial
Pasadena, TX  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Paradigm at Faith Memorial in Pasadena, TX — inspection on July 29, 2024.

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

FF0684
Provide appropriate treatment and care according to orders, resident?s preferences and goals.

resident would be seen out 911.

She said notifications should be made to the family, DON, ADON,

jeopardy to resident health or safety In an interview on 7/28/24 at 7:12 AM with LVN K said she was in serviced on the facility's fall policy.

She said all actions taken after a fall had to be documented.

She said a fall assessment, neuro

family and DON should be completed.

She said the facility placed a quick guide at the nurses' stations to reference the steps after a fall.

She said residents would be sent out 911 after a fall, if they had bleeding, unconscious, range of motion issues that indicated broken bones, and abnormal vitals.

Record review of facility Education In-services on Quick Guide - Falls, Change in Condition Communication, Neurological Neuro Checks, Fall Management, Investigation of Falls, Fall Management Post Test dated 7/26/24-7/28/24 revealed all staff were trained on the Fall Management Policies and tested on knowledge of the policies.

The Admin was informed the Immediate Jeopardy (IJ) was removed on 7/28/24 at 7:09 PM.

While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

F-F684: Quality of Care

The facility failed to obtain emergency services for unwitnessed fall for Resident #1 after a fall on 7/24/24 that resulted in bruising to a subdural hematoma to the left side of her head. Resident #1 arrived at the ER approximately two and a half hours after the injury had occurred.

On 7/24/24 Resident #1 was transferred to the hospital.

LVN A was suspended pending investigation 7/25/24 based on Self Report to HHSC.

The Administrator and Director of Nursing notified the Medical Director of the IJ on 7/26/24.

675321

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 675321 B.

Wing 07/29/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502

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 Pasadena, 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 at Faith Memorial or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

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.