Health inspection·December 10, 2025

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 of 2 residents (Resident #1) reviewed for oxygen.- The facility failed to ensure Residents #1 had an order for oxygen, when she was on 2L O2 via NC.This failure could place residents at risk for inadequate or inappropriate amounts of oxygen delivery and ineffective treatment.Findings included:Record review of Resident #1's undated face sheet revealed she was a [AGE] year old female admitted on [DATE] with diagnoses of acute and chronic respiratory failure (not enough oxygen in the blood), cerebral infarction (stroke), aphasia (unable to speak), type 2 diabetes mellitus (body does not produce insulin or resists it), pneumonitis (inflammation) due to inhalation of food and vomit, and a stage 3 pressure ulcer to her sacrum (pressure ulcer revealing fat but not to the bone, of her tailbone). The picture of the resident on the face sheet revealed she had oxygen on.Record review of Resident #1's admission MDS assessment dated [DATE] revealed a BIMS score of 0 out of 15, which indicated severely impaired cognition. The resident was dependent (the helpers did all the effort and resident does none of the effort) for all self-care and mobility. According to the MDS, the resident was on oxygen.Record review of Resident #1's Baseline Care Plan dated 9/5/25, revealed the resident was receiving oxygen and had a Focus: oxygen use: required supplemental oxygen, with a goal to maintain adequate oxygen saturation levels and respiratory comfort through the review date. The interventions included assessing for signs of hypoxia (not having enough oxygen), changing the tubing when soiled or contaminated, following physician orders for oxygen therapy delivery, monitoring for side effects of oxygen therapy (dry mucous membranes, oxygen toxicity) and report to MD as needed, monitor/clean the oxygen concentrator filter as needed, provide humidification as indicated, and routinely monitor the resident's oxygen saturation levels.Record review of Resident #1's Comprehensive Care Plan dated 9/5/25, revealed a Focus: Oxygen Use: required supplemental oxygen (Initiated: 9/8/25). The goal was to maintain adequate oxygen saturation levels and respiratory comfort through the review date (Initiated: 9/8/25, Target: 9/22/25). The interventions included following physician orders for oxygen therapy delivery, monitoring for side effects of oxygen therapy (dry mucous membranes, oxygen toxicity) and report to MD as needed and routinely monitor the resident's oxygen saturation levels.Record review of Resident #1's previous hospital records dated 9/3/25 at 12:53am by CRRT M, revealed she was on O2 at 2L via NC.Record review of Resident #1's Admission/readmission assessment dated [DATE] at 4:38pm by unknown nurse, revealed the resident was using O2 at 2 LPM.Record review of Resident #1's oxygen saturations from 9/5/25-9/23/25, revealed she was on oxygen via nasal cannula.Record review of Resident #1's Progress Notes dated 9/6/25 at 10:52am by LVN R, revealed the resident's O2 was 98% and the method was oxygen via nasal cannula. The note also said the resident was provided education on oxygen management.Record review of Resident #1's H&P dated 9/8/25 at 10:00am by NP C, revealed .Continues to require oxygen via nasal cannula Residents Affected - Few Page 1 of 3 455714 455714 12/10/2025 Paradigm Northwest 17600 Cali Dr Houston, TX 77090

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and nebulizer treatments.Will monitor respiratory status and oxygen saturation.Record review of Resident #1's H&P dated 9/22/25 at 8:00am by NP C, revealed .She was maintained on O2 via nasal cannula during this time.Continues to require oxygen via nasal cannula and nebulizer treatments.Will monitor respiratory status and oxygen saturation.Record review of Resident #1's Progress Notes dated 9/22/25 at 7:54pm by LVN S, revealed the resident's O2 was 99% and the method was oxygen via nasal cannula.In an observation on 9/23/25 at 9:23am, Resident #1 was lying on her right side in bed, with O2 at 2L via NC on.In an observation on 9/23/25 at 11:19am, Resident #1 was lying in bed with O2 via NC on.Record review of Resident #1's Physician Orders on 9/23/25, dated 9/5/25-9/23/25 by MD G, revealed no orders for oxygen.In an interview on 9/23/25 at 1:09pm, LVN H said Residents who were on oxygen had their pulse ox documented once per shift. She said if a Resident was on oxygen there would be an order for it, and they documented the pulse ox also. LVN H said there was not an order for oxygen in the chart for Resident #1. She did not feel that anything would happen to the resident being on oxygen without an order because the resident needed it.In an interview on 9/23/25 at 1:29pm, the Interim DON said the policy was there would be an order for oxygen, and then the nurse confirmed the resident was on the correct amount by documenting on the MAR-TAR the amount of oxygen the resident was on. She said if the resident was on oxygen, the nurse should have noticed there was not an order and called the MD to get one. The Interim DON said the nurse knew how much oxygen to put the resident on without an order, because the MD always ordered between 2-4 liters. She said she did not think anything would happen to the resident because she needed the oxygen.Record review of the facility's policy and procedure on Physician Orders (Revised 12/2024) read in part: All physician orders must be accurate, timely, and documented in the resident's medical record. Only authorized individuals (e.g., physicians, nurse practitioners, or physician assistants) may write or verbally provide orders. Verbal orders must be promptly documented, signed, and authenticated by the prescribing practitioner within the timeframe. The facility staff must ensure that all orders are obtained, clarified, and carried out promptly, with documentation. Orders for treatments, medications, or procedures may be requested or clarified during: Routine visits. As-needed communication for resident care changes.If an order is received verbally or via telephone: A licensed nurse or authorized staff member must document the order in the medical record immediately. The order must include: Resident's name. Date and time of the order. Specific details of the order. The name and title of the prescribing practitioner. The facility staff must transcribe and verify the order accurately into the medical record.Facility staff are responsible for: Reviewing the order promptly. Ensuring that all orders are correctly implemented within the timeframe specified. Communicating any barriers to implementation to the prescribing practitioner. Documentation of implementation must include: Date and time the order was carried out. Name and credentials of the staff member completing the task. Any resident responses or outcomes, as applicable. If clarification is required, the staff member must: Contact the prescribing practitioner for clarification. Document the clarification conversation and any modifications in the medical record. Record review of the facility's policy and procedure on Oxygen Therapy: General Administration & Care (Revised 8/2019) read in part: It is the policy of this facility that the facility will provide oxygen therapy by means of various administration devices.Start O2 flow rate at the prescribed liter flow.Document initiation of therapy in the medical record, per documentation standards.(Note: For oxygen saturation below 89% emergency use of oxygen from 2-4L is appropriate to prevent worsening of hypoxemia and negative outcomes. The physician should be notified, and an order obtained for continued use of oxygen as soon as medically practicable.) 455714 Page 2 of 3 455714 12/10/2025 Paradigm Northwest 17600 Cali Dr Houston, TX 77090

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen reviewed for food service safety.The facility failed to obtain the food temperatures of the lunch meal prior to serving residents on 10/4/25.The facility failed to ensure a storage bag of peaches, and a container of rice were properly labeled and dated.These failures could place residents at risk of food-borne illness. Findings Include:Record review of the facility's Production Sheet dated 10/4/25 revealed there were no food temperatures documented for the lunch meal which consisted of golden-brown oven fried chicken, black eyed peas, seasoned broccoli, buttered cabbage, chilled peaches, and a biscuit.In an interview on 10/7/25 at 10:00 a.m. the [NAME] said he prepared the lunch meal on Saturday 10/4/25 and did not take the food temperatures. He said the lunch meal was the biggest meal he had to prepare, and he got distracted. He said he tried a piece of the chicken to ensure it was done. He said he was previously trained by the DM on taking the food temperatures. He said the purpose of obtaining the food temperatures was to ensure the food was done and did not contain any bacteria. In an observation on 10/7/25 at 10:08 a.m. of the walk-in refrigerator with the DM revealed there was 1 plastic storage bag of peaches with no label or use by date and 1 silver container of cooked rice with no label or use by date.In an interview on 10/7/25 at 10:11 a.m. the DM said food should be labeled immediately. She said she normally completed rounds to verify that labels were present. She said the purpose of labeling and dating food was to know when it was made and when to toss it. She said she expected food temperatures to be obtained the moment the food is cooked to confirm the proper temperature and to avoid food borne illness. She said there was a high risk of foodborne illness spreading if the temperatures were not taken. In an interview on 10/7/25 at 1:15 p.m. the Administrator said anytime staff opened something it should be properly stored, dated and labeled before storing the item. She said the food temperature should be taken before each meal to ensure the food is not too hot or too cold and documented in the logbook. She said obtaining the temperatures was important to ensure the food is cooked to the right temperature for consumption purposes. She said if the temperatures were not taken, the food may be undercooked which could result in foodborne illness and make the residents sick, or the food could burn the residents. Record review of the facility's undated Nutrition Services Policies and Procedures policy revealed in part, .Subject: Safe Food Temperatures. Policy: It is the policy of this facility that food temperatures will be maintained at acceptable levels during food storage, preparation, holding, serving, delivery, cooling and reheating. Procedures. 7. Check and record trayline food temperatures on the food temperature record before each meal. If the food temperatures are not within acceptable parameters, reheat the food to at least 165F for 15 seconds (for hot foods) or discard it.Record of the facility's Nutrition Services Policies and Procedures policy dated 8/12/2019 revealed in part, .Food Safety in Receiving and Storage. General Food Storage Guidelines. 3. Place food that is repackaged in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight fitting lid. Label both the container and its lid with the common name of the contents and the date it was transferred to the new container. It is recommended that food stored in bins (e.g. flour or sugar) be removed from its original packaging. Refrigerated Storage Guidelines. 12. Refrigerated, ready to eat Time/Temperature Control for Safety Foods (TCS) are properly covered, labeled, dated with a use-by date and refrigerated immediately. [NAME] them clearly to indicate the date by which the food shall be consumed or discarded. The day of preparation or day original container is opened shall be considered day 1. Discard after three days unless otherwise indicated. Refer to Cold Storage Chart. 455714 Page 3 of 3