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 (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 2 Event ID: 675085 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 675085 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Woodwind Lakes 7215 Windfern Rd Houston, TX 77040 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)