Inspection visit
Health inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure residents who were incontinent of
bladder received appropriate treatment and services to prevent urinary tract infections and to restore
continence to the extent possible for 1 of 5 resident (Resident #24) reviewed for incontinent care.
-The facility failed to ensure CNA JJ and CNA RR properly cleaned Resident #24 during incontinent care.
This failure could place residents at risk for urinary tract infections (UTI), urethral erosions, discomfort, skin
breakdown, and a decreased quality of life.
Findings include:
Record review of the admission sheet (undated) for Resident #24 revealed an [AGE] year old female
admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included pneumonia
(Infection that inflames air sacs in one or both lungs, which may fill with fluid), congestive heart failure (a
chronic condition in which the heart doesn't pump blood as well as it should) and dysphagia (difficulty
swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete
and painful blockage).
Record review of Resident #24's Quarterly MDS, dated [DATE], revealed the BIMS score was 14 out of 15,
which indicated she was intact cognitively. The MDS revealed she was dependent from staff with toileting
hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear and personal hygiene. The
MDS revealed in section H0300: Urinary Incontinence was coded (3) always incontinent. section H0400:
Bowel Incontinence was coded (3) always incontinent.
Record review of Resident #24's care plan, initiated 05/21/2021 and revised on 09/01/2023 revealed the
following:
Focus: Resident#24 has bowel and bladder incontinence and is at risk for skin break down AEB cognitive
impairment. Goal: Resident#24 will remain clean, dry, odor free and no occurrence of skin breakdown will
occur over the next 90 days. Interventions: Change promptly and apply a protective skin barrier to the skin
as needed.
Observation on 03/27/24 at 2:33p.m., revealed CNA RR and CNA JJ provided Resident #24 with
incontinence care. CNA JJ removed Resident #24's brief and tucked it under the resident's buttocks. CNA
JJ did not spread Resident #24's labia to thoroughly clean the area and the resident's urinary meatus.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 10
Event ID:
455582
Printed: 05/15/2026
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
455582
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/28/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paradigm at Bay City
1800 13th St
Bay City, TX 77414
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
In an interview on 03/27/24 at 2:44p.m., with CNA JJ, she said she had been working at the facility for the
last 7 years as a full-time employee. CNA JJ said she did not spread Resident's labia and clean the
resident's meatus during incontinent care because I was nervous. She said the failure placed the resident
at risk for infections.
In an interview on 03/28/24 at 1:24 p.m., with the DON, she said she expected staff to make sure they
provided complete and proper incontinent care. She said CNAs were provided training and competency
check offs quarterly and as needed. At this time policy on perineal care was requested.
No policy on Perineal Care was provided on exit.
Record review of CNA JJ's Peri Care Competency Check off dated 01/26/23 and 01/8/24 revealed read in
part: .FEMALE considerations: Helps to flex knees and spread legs apart. Observe limitations in
positioning. Utilize bath towels or washcloths as indicated. Separate the labia, cleanse front to back with a
disposable wipe using downward strokes. Discard soiled gloves, wash hands, and DON clean gloves. Apply
barrier cream. Apply clean undergarment/brief as necessary. Remove gloves, wash hands, and dispose of
linen properly .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455582
If continuation sheet
Page 2 of 10
Printed: 05/15/2026
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
455582
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/28/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paradigm at Bay City
1800 13th St
Bay City, TX 77414
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to provide pharmaceutical services (including
procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and
biologicals, and disposing of expired medications) to meet the needs of each of resident for 1 (resident #27)
of 5 residents reviewed for gastrostomy (G-tube) medication administration in that:
LVN A's cart contained an insulin Glargine injection pen100 units/ML prefilled expired 03/26/24, and LVN
B's Enoxaparin 40mg/.4ml prefilled syringes expired on 03/27/24.
LVN A's cart contained expired low control glucose control solutions. expired 12/23 and the high control
expired 01/24.
These failures could place residents with G-tubes (Gastrostomy tube) at risk of g-tube replacement,
medical complications, or a decline in health due to inappropriate G-tube care, management, and not
following appropriate procedures.
Findings Include:
Observation on 3/27/24 at 9:30 a.m. of medication administration via g-tube , one (MiraLAX) medication
cup with condensation noted and two additional medication cups for G-tube medication administration at
bedside. LVN checked residual as ordered and administered 30 milliliters (mls) of water initial [NAME] via
gravity but used plunger to initiate the 30mls of water flow. She removed the plunger and administered
liquid medications with water flush in between each medication. The cup was noted to still be cool to touch
after medication administration.
In an interview 03/27/24 at 9:40 a.m. with the LVN A, she said, the cup was cold but has been sitting out for
a while to do his g-tube medication. She said the risk of using the plunger and using cold fluids for g-tube
was that the resident may feel discomfort . She said, I know I'm not supposed to use it, but it was going in
too slow.
Observation on 3/27/24 at 10:43 a.m. revealed an insulin Glargine injection pen100 units/ML prefilled with
an opened date of 02/27/24; expired located inside of LVN A's cart.
Observation on 3/27/24 at 10:44 a.m. revealed high and low glucose control solutions (used to perform
Glucose Meter quality checks) expired inside the cart. The low control expired 12/23 and the high control
expired 01/24.
During an interview on 3/27/24 at 10:45 a.m. LVN A confirmed the insulin Glargine injection 100 units/ML
prefilled pen had an expiration date of 3/27/24. She said, it should have been discarded. She said, the risk
of having expired insulin was that the resident may not receive the correct amount needed. LVN A said, the
evening shift checks controls for the blood glucose meters, and the risk of using expired control solutions to
test the blood glucose meters was getting the incorrect reading.
Observation and interview on 03/28/24 at 12:30 p.m. with the ADON, she accompanied this surveyor to
LVN B's cart, and she confirmed there were three Enoxaparin 40mg/.4ml syringes with expiration date of
03/27/24. She said, the medications should have been removed from the cart as soon as they were
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455582
If continuation sheet
Page 3 of 10
Printed: 05/15/2026
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
455582
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/28/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paradigm at Bay City
1800 13th St
Bay City, TX 77414
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 0755
expired, especially since the resident had not returned to the facility after his appointment.
Level of Harm - Minimal harm
or potential for actual harm
Record review of Resident # 27's face sheet revealed a [AGE] year-old male admitted on [DATE] with
diagnoses of Displaced fracture of the right humerus (upper arm fracture), aphasia (a language disorder
that makes it hard for you to read, write, and say what you mean to say), and aphonia (a loss of voice such
as partial hoarseness or complete whisper).
Residents Affected - Few
Record review of the MDS dated [DATE], revealed Resident #27 had no BIMS score documented.
Record review of nurse notes dated 03/27/24 indicated the resident had a change of conditioned on
03/26/24 due to a weak g-tube after several attempts to unstop g-tube. Resident had a new 18 French
g-tube exchanged by the physician on 03/26/24 at 1:46 p.m.
Observation and interview on 03/28/24 at 12:30 p.m. with the ADON, she accompanied this surveyor to
LVN B's cart, and she confirmed there were three Enoxaparin 40mg/.4ml syringes with expiration date of
03/27/24. She said, the medications should have been removed from the cart as soon as they were
expired, especially since the resident had not returned to the facility after his appointment.
Record review of the facility's policy and procedure titled, Storage of Medications, not dated, read in part .
Medication and biologicals are stored safely, securely, and properly, following manufacturer's
recommendations are those of the suppliers. The medication supply is accessible only to licensed nursing
personnel, pharmacy personnel, our staff members lawfully authorized to administer medication.
Procedures:2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer
medications are permitted to excess medications. Medication rooms, carts, and medication supplies are
locked when not attended by persons with authorized access. Expiration dating (Beyond-use dating):7. No
expired medication will be administered to a resident. 8. All expired medications will be removed from the
active supply and destroyed in the facility, regardless of amount remaining. The medication will be
destroyed in the usual manner
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455582
If continuation sheet
Page 4 of 10
Printed: 05/15/2026
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
455582
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/28/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paradigm at Bay City
1800 13th St
Bay City, TX 77414
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were
secured properly for 1 of 5 medication carts reviewed for pharmacy services in that:
The facility failed to ensure LVN A did not leave 1 optic medication on top of the medication cart
unsupervised.
This failure placed residents at risk for unauthorized access to the medication cart and consumption of
harmful medications, misappropriation, and drug diversion.
Findings included:
Observation on 3/27/24 at 10:42 a.m. revealed LVN A's med cart unattended with optic (eye drops)
medication located on top of medication cart.
During an interview on 3/27/24 at 10:45 a.m. with LVN A, she said, all medications should be locked inside
the carts. She said, the risk of leaving eye drops out, was that another resident could pick it up and start
using it or drinking it.
Record review of the facility's policy and procedure titled, Storage of Medications, not dated, read in part .
Procedures: 2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer
medications are permitted to excess medications. Medication rooms, carts, and medication supplies are
locked when not attended by persons with authorized access. Expiration dating (Beyond-use dating) .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455582
If continuation sheet
Page 5 of 10
Printed: 05/15/2026
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
455582
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/28/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paradigm at Bay City
1800 13th St
Bay City, TX 77414
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 0814
Dispose of garbage and refuse properly.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review, the facility must dispose of garbage and refuse properly
for 1 of 1 dumpster reviewed for garbage disposal.
Residents Affected - Few
-The facility failed to ensure the dumpster lids and doors were secured.
This failure could place residents at risk of infection from improperly disposed garbage.
Findings included:
Observation on 03/26/24 at 8:41 a.m., revealed the facility's dumpster area, which was in the lot on back
side of the facility had a commercial size with top lid completely open.
Interview on 03/26/24 at 8:45 a.m., with the Dietary Manager, she stated it was the dietary responsibility
that the dumpster doors always must be closed to keep insects and trash out of the dumpster and from
entering the facility. She stated housekeeping might have left it open because they throw night's trash out in
the morning.
In an interview on 03/26/2024 at 3:03p.m., with the Administrator and the DON, the Administrator said she
expected the dumpster to be completely closed, and if it was found open, then it should be closed. She said
failure to close the lid could cause trash coming out and infection control issue. The DON said the facility
would re-educate and monitor that it stayed closed.
Record review of the facility's waste Disposal policy (Revised 6-2019) revealed read in part: .Policy: Waste
will be disposed of in a manner to prevent transmission of disease, nuisance or breeding place for insects
and feeding places for rodents and other mammals. PROCEDURES: 5. Cover waste containers and close
dumpsters at all times .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455582
If continuation sheet
Page 6 of 10
Printed: 05/15/2026
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
455582
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/28/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paradigm at Bay City
1800 13th St
Bay City, TX 77414
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews, and record review the facility failed to ensure clinical records were maintained in accordance
with accepted professional standards and practices, were complete, and accurately documented for 1
(Resident #13) of 5 residents reviewed for clinical records.
LVN B failed to document Insulin administration on the eMAR on 03/04/24, 03/11/24, 03/15/24,03/19/24,
03/20/24 and 03/27/24.
This failure could place residents at risk inappropriate and inadequate medication administration and a
decline in health status.
Findings included:
Review of Resident #13's revised face sheet dated 03/27/24 reflected a [AGE] year-old male who was
initially admitted to the facility on [DATE] with diagnoses including, type 2 diabetes mellitus with unspecified
complications (high blood sugar), essential (primary) hypertension (high blood pressure), and cerebral
infarction (disrupted blood flow to brain).
Record review of Resident# 103's MDS assessment, dated 02/01/24, revealed that his BIMS score was a
09 (Moderate cognitive impairment).
Record review of Resident #13's Physician's orders dated on 8/22/23 for Novolog Injection solution 100
unit/ml revealed, Inject sliding scale: if 150-200=3 units; 201-250=5 units; 251-300= 7 units; 301-350 =10
units; 351-400=12 units; If Blood sugar greater than 400, give 12 units and call MD immediately.
Record review of Resident #13's March 2024 eMAR and eTAR revealed the following blood sugars without
documented nursing interventions (medication administration and/or contact made to physician):
3/04/2024 at 0800: 463 mg/dl
3/04/2024 at 1600: 444 mg/dl
3/11/2024 at 1600: 463 mg/dl
3/15/2024 at 1600: 444 mg/dl
3/19/2024 at 1600: 440 mg/dL
3/20/2024 at 1600: 427 mg/dL
3/27/2024 at 0800: 540 mg/dl
During an interview with the DON and the Regional nurse on 3/27/24 at 1:05 p.m., the DON and Regional
Nurse were not aware of the elevated Blood glucose for Resident #13. They said that the expectation was
to contact the MD immediately if the resident's blood glucose levels were outside the sliding
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455582
If continuation sheet
Page 7 of 10
Printed: 05/15/2026
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
455582
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/28/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paradigm at Bay City
1800 13th St
Bay City, TX 77414
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
scale parameters as ordered. The Regional nurse said, there was no risk because the nurse administered
the 12 units of insulin and contacted the doctor; however, she just did not document her interventions . The
DON stated that the risk of not documenting any interventions was that other nurses were not aware of
what was going on with the resident and the need for proper follow-up by the staff.
During an interview on 3/27/24 at 2:46 p.m. with LVN B, she stated, she checked the Sliding scale order for
Resident #13 based on the eMAR, and the resident had a BS of 540 mg/dl which was on her personal
notepad . She said she called the doctor and administered 12 units of Insulin but does not know the exact
time. She said, if the resident's blood sugar reading was too high or too low, the system would not allow her
to add the medication on the eMAR, and the progress notes would populate. LVN B said, she contacted the
NP today and left a voicemail message. She rechecked resident A's blood sugar around 11:00 a.m. and it
was down to 449 mg/dl. She said, she contacted the doctor because the NP had not called back. She said,
when the MD called, he gave a new order for 15 units of Levemir between 1:45pm-200pm. LVN said, she
should have documented in the nurse's notes that she contacted the physician and documented on the
MAR that 12 units of insulin was administered. She said, if it isn't documented, it means that it wasn't done.
LVN B said, the risk of not documenting was that someone else could have administered more medications
because they would not have known that it was administered based on the MAR.
During an interview on 3/28/24 at 2:46 p.m. with the Nurse Practitioner, she said that the initial contact with
LVN B was on 03/27/24 at 1:11p.m. LVN B texted the resident's 540 mg/dl blood sugar reading. She stated
the text was followed by a call at 1:40 p.m. and a new order was given for regular insulin and a nightly order
for Levemir 15 Units.
Requested policy for Medication administration from DON, and the policy had not been received by exit.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455582
If continuation sheet
Page 8 of 10
Printed: 05/15/2026
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
455582
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/28/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paradigm at Bay City
1800 13th St
Bay City, TX 77414
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to establish and maintain an infection prevention
and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent
the development and transmission of communicable diseases and infection for 1 of 4 residents (Resident
#24) reviewed for infection.
Residents Affected - Few
-The facility failed to ensure CNA JJ and CNA RR performed hand hygiene during incontinent care on
Resident #24.
This failure could lead to the spread of infection to residents, resident illness, and/or resident distress.
Finding include:
Record review of the admission sheet (undated) for Resident #24 revealed an [AGE] year old female
admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included pneumonia
(Infection that inflames air sacs in one or both lungs, which may fill with fluid), congestive heart failure (a
chronic condition in which the heart doesn't pump blood as well as it should) and dysphagia (difficulty
swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete
and painful blockage).
Record review of Resident #24's Quarterly MDS, dated [DATE], revealed the BIMS score was 14 out of 15,
which indicated she was intact cognitively. The MDS revealed she was dependent from staff with toileting
hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear and personal hygiene. The
MDS revealed in section H0300: Urinary Incontinence was coded (3) always incontinent. section H0400:
Bowel Incontinence was coded (3) always incontinent.
Record review of Resident #24's care plan, initiated 05/21/2021 and revised on 09/01/2023 revealed the
following:
Focus: Resident#24 has bowel and bladder incontinence and is at risk for skin break down AEB cognitive
impairment. Goal: Resident#24 will remain clean, dry, odor free and no occurrence of skin breakdown will
occur over the next 90 days. Interventions: Change promptly and apply a protective skin barrier to the skin
as needed.
Observation on 03/27/24 at 2:33p.m., revealed CNA RR and CNA JJ provided Resident #24 with
incontinence care. CNA JJ removed Resident #24's brief and tucked it under the resident's buttocks. CNA
JJ did not spread Resident #24's labia to thoroughly clean the area and the resident's urinary meatus. CNA
RR assisted Resident #24 to turn her onto her left side in order to clean her buttocks. Resident had a large
bowel movement. CNA JJ without removing her soiled gloves, tucked the clean brief under the resident's
buttocks. At this time CNA ZZ knocked on Resisdent#24's door. CNA JJ asked CNA ZZ for the barrier
cream and gloves. CNA ZZ handed CNA JJ barrier cream packets and a pair of gloves. CNA JJ placed
gloves in her pocket, closed the door and without sanitizing her hands placed gloves from her pocket and
applied barrier cream on the resident's buttocks. CNA RR and CNA JJ completed perineal care and with
the same soiled gloves on, touched the Resident's clean shirt, brief, sheet, and blanket. Both CNA JJ and
CNA RR left the room without sanitizing or washing their hands.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455582
If continuation sheet
Page 9 of 10
Printed: 05/15/2026
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
455582
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/28/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paradigm at Bay City
1800 13th St
Bay City, TX 77414
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 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
In an interview on 03/27/24 at 2:42p.m., with CNA RR, she said she did good assisting CNA JJ. She said
CNA JJ should have changed her gloves, washed her hands, or used hand sanitizer before placing clean
brief on. She said the failure placed the resident at risk for infections.
In an interview on 03/27/24 at 2:44p.m., with CNA JJ, she said she had been working at the facility for the
last 7 years as a full-time employee. CNA JJ said she did not spread Resident's labia and clean the
resident's meatus during incontinent care because I was nervous. She said the failure placed the resident
at risk for infections. She said she did not recall doing CNA competency checks for incontinent care. CNA
JJ said she had performed hand hygiene during the delivery of incontinent care to Resident#24. CNA JJ
said, I went across Resident#24's room and used the hand sanitizer that was sitting on the med cart. At this
time the Surveyor shared her observation from earlier that the Surveyor did not observe her step out of
Resident#24's room and observed CNA ZZ hand her packets of barrier cream and gloves. CNA JJ said her
actions in not performing hand hygiene while changing gloves could result in cross contamination. She said
she had completed in-service on infection control last month and could not recall the exact date.
In an interview on 03/27/24 at 2:48p.m., with CNA ZZ, she said she handed CNA JJ a pair of gloves and
barrier cream packets when she came to check if CNA JJ and RR needed her assistance during
incontinent care.
In an interview on 03/28/24 at 1:24 p.m., with the DON, she said she expected staff to make sure they
provided complete and proper incontinent care. She said CNAs should have either washed or sanitized
their hands after touching a dirty area prior to moving to a clean area when performing incontinent care.
She said these failures were risk for infection control. She said staff received training/in-service on infection
control often. She said CNAs were provided training and competency check offs quarterly and as needed.
At this time policy on perineal care was requested.
Record review of the facility's Hand Hygiene policy (Revised 6/2019) revealed read in part: .It is the policy
of this facility that proper hand hygiene/hand washing technique will be accomplished at all times that
handwashing is indicated. Hand Hygiene/Hand washing is the most important component for preventing the
spread of infection. Procedure: After: After removal of medical/surgical or utility gloves. NOTE: Wash hands
at end of procedures where glove changes are not required. For procedures in which change of gloves,
e.g., clean gloves to sterile gloves, is indicated follow the specific standard of practice. However, hand
washing may not be necessary until completion of the procedure. If glove hands become contaminated as
gloves are changed hands can be washed. Contact with a patient's/resident's intact skin (e.g. taking a pulse
or blood pressure, performing physical examinations, lifting the patient/resident inn bed .
Record review of the Infection Control Program (Revised 2/2022) revealed read in part: .Policy:
Evidence-based policies and procedures are the foundation of a facility's infection control and prevention
program. Goals: A Decrease the risk of infections and communicable diseases to residents, employees,
volunteers, and visitors .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455582
If continuation sheet
Page 10 of 10
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Back to topCitations
6 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the March 28, 2024 survey of PARADIGM AT BAY CITY?
This was a inspection survey of PARADIGM AT BAY CITY on March 28, 2024. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PARADIGM AT BAY CITY on March 28, 2024?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, an..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.