Health inspection·July 22, 2025

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviewed, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #1) of 5 residents reviewed for quality of care. Resident #1's Dialysis Hand Off Communication Report forms were not completed or incomplete for 22 out of 23 opportunities. This failure placed residents at risk of unrecognized dialysis complications. The findings included: Record review of Resident #1's admission Record, dated 07/11/25, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included type 2 diabetes mellitus (high levels of sugar in the blood) with diabetic neuropathy (nerve damage), cognitive communication deficit, acute on chronic systolic (congestive) heart failure, and unspecified atrial fibrillation (irregular heart rhythm). Record review of Resident #1's MDS Quarterly Assessment, dated 06/24/25, revealed a BIMS score of 15, indicating she was cognitively intact. Further review revealed resident required a helper to complete toileting, shower/bathe, and upper and lower body dressing. Further review revealed she had an active diagnosis of renal insufficiency, renal failure, or end-stage renal disease and received dialysis.Record review of Resident #1's care plan report, undated, revealed the resident received dialysis Tuesday, Thursday, and Saturday, and was at risk for SOB, chest pain, elevated blood pressure, infected access site, itchy skin, bleeding at access site, etc. AEB DX end stage renal disease. Record review of Resident #1's physician orders, undated, revealed the following orders: Dialysis: May go to Dialysis on: Tuesday, Thursday, Saturday, one time a day every Tue, Thu, Sat for ESRD.start 04/19/25. discontinue 06/04/25.Pre-Dialysis Vital Signs, every day shift every Tue, Thu, Sat for Dialysis.start 03/15/25.discontinue 06/04/25.Post Dialysis Vital Signs, every day shift every Tue, Thu, Sat for Dialysis.start 03/15/25.discontinue 06/04/25.Dialysis: May go to Dialysis on: (Tuesday, Thursday and Saturday).every day shift every Tue, Thu, Sat for Dialysis.start 07/12/25.end indefinite.Pre-Dialysis Vital Signs, one time a day every Tue, Thu, Sat.start 07/12/25.end indefinite.Post-Dialysis Vital Signs, one time a day every Tue, Thu, Sat.start 07/12/25. end indefinite. Record review revealed Resident #1's Dialysis Hand Off Communication Report forms revealed the following:*there was a total of 5 Report forms since May 2025; *There were 0 out of 14 report forms accounted for and reviewed for May 2025, and *5 out of 9 report forms were accounted for and reviewed for July 2025 (7/2, 7/8, 7/12, 7/15, and 7/17). 1 out of the 5 report forms was completed and the other 4 were incomplete. During an interview on 07/22/25 at 1:10 p.m., the Interim DON said the charge nurse completed the top portion of the form and sent it with the resident to dialysis and dialysis completed the bottom portion of the form and the form was returned back to the facility with the resident. She said she did not know how long it had been the process, but it was the current process to keep it in a binder. She said it was the unit managers responsibility to ensure the nurse was completing the process and reviewing the form for changes, but changes were not Residents Affected - Few Page 1 of 2 675085 675085 07/22/2025 Paradigm at Woodwind Lakes 7215 Windfern Rd Houston, TX 77040

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few typical. She said the dialysis process was reviewed monthly by administration. She said when a resident was on dialysis, they have their set date, they received their morning care and medications prior to dialysis, they had their meal, waited for transportation, and during this time they had their vital signs checked and recorded on the dialysis form. She said the form was provided to the transportation service as well as with the resident, and the resident was transported to the dialysis center. She said those that get in house dialysis were usually taken to the dialysis center by the CNA. Record review of the facility's Dialysis Hemodialysis policy, undated, read in part .2. The facility staff will participate in ongoing communication with the dialysis center by using the Dialysis Communication Form which is filed in the resident's medical record. 675085 Page 2 of 2