Inspection visit

Health inspectionJanuary 10, 2024

Paradigm at Faith MemorialCMS #6753215 citations on this visit

5 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the resident and/or representative had the right to participate in the development and implementation of his or her person-centered plan of care, and to ensure that the planning process facilitated the inclusion of the resident and/or representative for one (Resident #42) of six residents reviewed for participation in care plan. The facility failed to ensure the IDT included Resident #42's RP, in the review of his comprehensive assessment and were able to discuss his individualized care needs for services to include his need for medical and nursing care, medications, therapy, psychological, and dietary needs. The failure could affect residents by placing them at risk for not receiving adequate or individualized care. Findings included: Record review of Resident #42's admission Record dated 1/10/24 revealed a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of thrombocytopenia, (low platelet level), alcoholic cirrhosis of liver with ascites, (a stage of acute liver disease where the liver has become significantly scarred with abdominal swelling), portal hypertension (elevated blood pressure in the portal venous system (the portal vein is a major vein that leads to the liver) the most common cause of cirrhosis or scarring of the liver), and cerebral infarction (the pathological process that results in an area of dead tissue in the brain caused by disrupted blood supply and restricted oxygen supply to the brain. The admission Record reflected 2 other family members as RP's. Record review of Resident #42's Quarterly MDS assessment dated [DATE] revealed his BIMS score was not assessed and his SAMS revealed he was coded as severely impaired for cognitive skills for daily decision making. The assessment reflected no physical or verbal behaviors, no rejection of care or wandering. Resident #42 required setup or clean-up assistance with eating and partial to moderate assistance with oral and personal hygiene, toileting, shower/bathing, upper/lower body dressing, rolling left to right, sit to lying, sit to stand and all other transfers and, used a wheelchair for ambulation. Resident #42 was always incontinent of bowel and bladder, and received antipsychotic, antianxiety, insulin and opioid medications on a routine basis. Record review of Resident #42's EMR revealed a care plan meeting dated 8/25/23. There were no other documented care plan meeting notes. (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 11 Event ID: 675321 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 675321 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502 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 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview with Resident #42's RP on 1/8/24 at 11:55 am, they said that they had not participated in any care plan meetings since last summer and the facility staff were hard to contact via telephone. The RP said that they periodically tried to reach staff including the SW and would leave messages and no one ever returns their telephone calls. In an interview with the SW on 1/8/24 at 1:38 pm, she said she was responsible for scheduling, setting up, and attending care plan meetings for all the residents. The SW said she was the permanent SW for the facility for 4 years and was no longer corporate. The SW said that the care plan meetings should occur at least every 3 months (quarterly). She said that Resident #42's last care plan meeting was 8/25/23. The SW said that Resident #42's RP was busy and seemed to be rushed when they visited so, the SW did not want to bother them. The SW said that Resident #42 was on hospice care services and had been expected to pass away. The SW then said that Resident #42 should have had a care plan meeting on or around 11/25/23 but had been in the hospital at that time. She said she did not know why she did not reschedule the care plan meeting once he returned to the facility on the same day (11/25/23).and she said that she needed to schedule a care plan meeting for the resident and did not know why she had not set up a meeting yet. The SW said that all residents should have a care plan meeting to review care needs and any changes to their plans of care . Subsequent record review of Resident #42's EMR on the last day of survey 1/10/24 revealed in part: Progress Notes NEW: Effective Date: 1/10/2024 8:35 Type: Care Conference Summary .Reason for Care Conference: (annual, quarterly, significant change): Follow-up with concerns from RP Record review of the facility's policy titled, Nursing Policies and Procedures, dated as revised 6/2019 revealed in part: A comprehensive care plan will be developed within 7 days after the completion of the comprehensive assessment . to the extent possible, the participation of the resident, the resident's family and/or responsible party should participate in the development of the care plan .every effort will be made to schedule care plan meetings to accommodate the availability of the resident and family or responsible party .Scheduling and preparation of the care plan meeting calendar is completed by the MDS Coordinator or designee .The MDS Coordinator and or designee will notify the resident, family and/or responsible party, and other interested parties designated by the resident, of the date and time of the care plan conference at least one week prior to the meeting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675321 If continuation sheet Page 2 of 11 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 675321 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. 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 review the facility failed to complete and transmit an MDS for 2 of 3 (CR #31& CR #95) residents reviewed for closed records. Residents Affected - Few 1 The facility failed to complete and transmit a discharge MDS for Resident #31 2 The facility failed to complete and transmit admission and discharge MDS for CR #95 These failures could place residents at risk of facility not providing complete and specific information for payment and quality of measure purposes. Finding included: CR #31 Record review of CR #31's Face sheet, on 01/10/24 revealed an [AGE] year-old male, initially admitted to the facility on [DATE] readmitted on [DATE] and discharged from the facility on 09/22/23. Record review of CR #31's MDS transmission records indicated the last MDS transmission was dated 08/29/23 and coded as admission MDS. Record review revealed no discharge MDS. Record review of CR #31's nurses note dated 09/22/23 at 1:00PM read in parts resident discharged from the facility. CR #95 Record review of CR #95's electronic Face sheet, on 01/10/24 revealed a [AGE] year-old male, initially admitted to the facility on [DATE] readmitted on [DATE] and discharged from the facility on 08/29/23. His diagnoses included sepsis (infection), admitting diagnosis encephalopathy (disease that affects brain structure or function), chronic kidney disease, acute embolism, thrombosis of [NAME] ([NAME] disease), anemia, anxiety, urine retention, benign prostatic hyperplasia with lower urinary tract symptoms, and lack of coordination. Record review of CR #95' admission MDS dated [DATE]was sign as completed on 10/20/23, 32 days after admission. Record review of nurse's notes dated 12/21/23 read in part: resident found unresponsive. hospice contacted. RP contacted. RN with hospice present. resident time of death 04:49. Record review of CR #95's MDS transmission revealed no records of discharge MDS for CR #95 During an interview with MDS Coordinator on 01/10/23 at 1:30PM, she said the discharge MDS was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675321 If continuation sheet Page 3 of 11 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 675321 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502 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 0640 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete overlooked, and she would initiate the discharge MDS. She said it was a human error. She said she had no explanation but would correct it. She said she was responsible for completing the MDS timely and getting it to the RN for signature. She said the facility was without a certified MDS for sometimes. She said the facility would have something in place to track uncompleted MDS's. Policy on MDS completion was requested from the MDS coordinator. Provided MDS policy dated 06/2019. titled Nursing policies and Procedures. Subject: Minimum Data set- policy which did not address failure to complete MDS assessment. Event ID: Facility ID: 675321 If continuation sheet Page 4 of 11 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 675321 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502 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 0641 Ensure each resident receives an accurate assessment. 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 review the facility failed to accurately assess each resident's cognitive status for 2 of 18 residents (Resident #28, #42), reviewed for assessment accuracy. Residents Affected - Few - The facility failed to accurately assess and document Resident #42's cognitive patterns on two different consecutive MDS assessments, and Resident # 28's Annual MDS reflected he had all his natural teeth. These failures could place residents at risk of not having accurate assessments, which could compromise their plan of care. Findings included: Resident #42 Record review of Resident #42's admission Record dated 1/10/24 revealed a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of thrombocytopenia, (low platelet level), alcoholic cirrhosis of liver with ascites, (a stage of acute liver disease where the liver has become significantly scarred with abdominal swelling), portal hypertension (elevated blood pressure in the portal venous system (the portal vein is a major vein that leads to the liver) the most common cause of cirrhosis or scarring of the liver), and cerebral infarction (the pathological process that results in an area of dead tissue in the brain caused by disrupted blood supply and restricted oxygen supply to the brain. Record review of Resident #42's Significant change in status MDS assessment dated [DATE] revealed he was coded in section B Hearing, Speech, and Vision as sometimes understood- ability is limited to making concrete requests and sometimes understands-responds adequately to simple, direct communication only. Further record review revealed in part of section C for Cognitive Patterns .C0100. Should Brief Interview for Mental Status be Conducted? Was coded 0. No ( resident is rarely/never understood). Resident #42 was coded as having a SAMS score indicating he was severely impaired for cognitive skills for daily decision making. Record review of resident #42's Q MDS assessment dated [DATE] revealed he was coded as sometimes understood- ability is limited to making concrete requests and sometimes understands-responds adequately to simple, direct communication only. Further record review revealed in part of section C for Cognitive Patterns .C0100. Should Brief Interview for Mental Status be Conducted? Was coded 0. No (resident is rarely/never understood). Resident #42 was coded as having a SAMS score indicating he was severely impaired for cognitive skills for daily decision making . In an interview with SW on 1/8/24 at 1:38 pm she said she was responsible for completing sections B, C, D, E, F and Q of the MDS. She said she had worked at the facility for 4 years. She said she had completed Resident #42's Significant Change MDS dated [DATE] and the 12/1/23 Q MDS for Resident #42. The SW said that she coded Resident #42 incorrectly on both the 8/31/23 and 12/1/23 MDS assessments. She stated she should have attempted a BIMS if she coded that the resident was sometimes understood and sometimes understands. The SW said she did not know why or how she coded Resident #42's assessment incorrectly. The SW said she thought the corporate MDS signed attesting to the accuracy of the MDS' once completed. She said she had not been formally trained on how to complete the MDS . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675321 If continuation sheet Page 5 of 11 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 675321 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with the Corporate MDS on 1/10/24 at 12:36pm who said that the BIMS assessment should have been attempted on Resident #42's Significant Change MDS dated [DATE] and on the 12/1/23 Quarterly MDS, based in the information the SW coded in section B on both MDS's. She said that she did not sign any MDS' in attestation of accuracy and could not speak to how accurate of an MDS it was. She said Resident #42's 8/31/23 and 12/1/23 assessments should and could be modified for accuracy because a resident should always have an accurate assessment as part of their plan of care . Resident #28 Record review of Resident #28's electronic face sheet on 01/10/24 revealed a [AGE] year-old male, initially admitted to the facility on [DATE] readmitted on [DATE] and readmitted on [DATE]. His diagnoses included Diabetes mellitus due to underlying condition with diabetic neuropathy, history of traumatic brain injury, essential hypertension, sequelae of cerebral infarction (A condition resulting from long time brain damage), constipation (inability to have regular bowel Record review of Resident #28's annual MDS assessment dated [DATE] section L oral denture section B no natural teeth or tooth decay was left blank. Section L Z was checked as None of the above indicating Resident #28 had all his natural teeth and no issue. Record review of Resident #28's care plan with a revision date of 04/19/21 and a target date of 03/12/24 revealed Resident #28 is at risk for has oral/dental health problems (r/t no teeth) Intervention: Provide mouth care as per ADL personal hygiene . Observation on 01/08/24 at 11:00AM, revealed he was in bed sleeping. He had a G-tube on at 55 cc per hour. He was clean and dry. Observation on 01/08/24 at 2:00Pm revealed he was in bed. He was awake, alert, and oriented to his name. He did not speak much but was able to say good. He was not interviewable to answer detailed questions. He could only answer yes and no questions. During an interview with the MDS nurse on 01/10/24 at 1:30 PM, she said she was responsible for ensuring that the MDS assessment accurately reflected resident's condition. She said she worked remotely and occasionally visit each resident at the facility. She said she completed the MDS by reviewing documentations from all disciplines and importing the findings into the MDS. She stated Resident #28 had no natural teeth. She said the MDS was coded wrong. She said inaccurate assessment may prevent residents from getting the care needed. She said she would modify the MDS and submit it . Record review of Facility's policy on resident assessment dated 06/2019 read in part: It is the policy of this facility that a registered nurse will conduct or coordinate each assessment with the interdisciplinary team. An MDS, which is a comprehensive, accurate, standardized reproducible assessment will be completed for each resident, using the RAI process. Facility staff complete a comprehensive assessment of each resident's needs, strengths, goals, life history, and preferences, and offer guidance for further assessment once problems have been identified. The comprehensive assessment is completed initially and periodically. Quarterly and Significant Change assessments are completed as required, following the RAI specific guidelines. State-specific versions of such assessments are completed within the required timeframes according to applicable law and regulations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675321 If continuation sheet Page 6 of 11 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 675321 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502 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 0641 MDS Accuracy Level of Harm - Minimal harm or potential for actual harm MDS 3.0 Internal Audit Tool Residents Affected - Few 1) The MDS 3.0 Internal Audit Tool will be completed on 1 MDS weekly, alternating between PPS and OBRA assessments. 2) The review is NOT to be completed by the MDS nurse that completed the MDS under review. 3) For the review, select the most recently completed MDS assessment. 4) The goal is for a 100% correct match between the facility and reviewer columns. 5) Identify reason(s) for differences and educate to reduce differences. 6) Monitor discrepancies over time Each assessment must represent an accurate picture of the resident's status during the observation period of the MDS. When the MDS is completed, only those occurrences during the observation period will be captured on the assessment. If it did not occur during the observation period, it is not coded on the MDS. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675321 If continuation sheet Page 7 of 11 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 675321 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observation, interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the Interdisciplinary team after each assessment for 1 of 18 residents reviewed for care plan accuracy (Resident # 20). --Resident #20 did not have a care plan for Hospice services, which began 6/20/23. This failure placed residents at risk of not receiving care and services according to their needs. Findings include: Record review of Resident #20's undated face sheet revealed admission date 8/31/2020 with diagnoses including degenerative disease of nervous system (disease that gradually destroys parts of the nervous system), Schizophrenia (serious mental disorder that affects people's perception of reality), borderline personality disorder (mental disorder characterized by unstable moods and behavior), epilepsy (sudden episode of sensory disturbance), contracture (hardening of muscles and tendons), tachycardia (irregular heart beat), and hypertension (high blood pressure). Record review of the Quarterly MDS revealed Resident #20 had severely impaired cognitive status, rarely or never understood others, and was rarely or never understood by others, required total assistance with all ADLs, and received Hospice care services. Record review of Resident #20's Hospice care plan revealed admission to Hospice services on 6/20/23 due to 8/31/20 diagnosis of degenerative disease of nervous system. Hospice plan of care dated 6/20/23 revealed medical, spiritual, personal care services to be supplied by Hospice nurse, chaplain, social worker, and home health aide. Observation of resident #20 on 1/8/24 at 10:05 am revealed he was in bed, covered by a blanket, sleeping, with feeding tube running and infusing formula. Observation of Resident #20 on 1/8/24 at 1:15 pm revealed he was in bed, covered by a blanket, awake but not responding to questions. Interview with CNA S on 1/8/24 at 1:30 pm revealed Resident #20 needed total assistance with ADLs, and he rarely spoke to anyone. Nurses checked his feeding tube every day and the CNA's checked on him every shift, at least every 2 to 3 hours. Record review of Resident #20's undated care plan revealed there was no care plan for Hospice. In an interview with MDS nurse on 1/10/24 at 3pm revealed the care plans are completed by the MDS nurse after documentation from nurses, doctor, social worker, hospital records if applicable, and are done 21 days after admission. She said if there were any changes in resident condition she would be notified by the Interdisciplinary team and she would update the care plan, but Hospice for resident #20 must have been missed. She said the risk of not having an accurate care plan would be that the resident would not receive correct care. In an interview with the interim DON on 1/10/24 at 3:10 pm, she said the care plan needed to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675321 If continuation sheet Page 8 of 11 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 675321 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete accurate for the resident's care, and the risk of having an inaccurate care plan would be residents' would not receive care according to their individual condition. Record review of facility policy Careplan Revisions, revised 5/22, revealed, in part: .comprehensive care plans will be reviewed and revised every quarter, when resident experiences a status change, and as deemed necessary . Event ID: Facility ID: 675321 If continuation sheet Page 9 of 11 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 675321 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502 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 maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection for 1 (Resident #36) of 5 resident reviewed for infection control. Residents Affected - Few The facility failed to ensure that the Wound Care Nurse implemented appropriate use of PPE and transmission-based precautions prior to enter and exiting Resident #36 room. Resident #36 was ordered Contact Isolation for MRSA of the right foot wound. This failure has the potential to affect residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections. Findings Included: Record review of Resident #36's face sheet dated 01/10/2024 revealed resident was admitted to the facility on [DATE], age [AGE] years old. Resident #36 had a diagnosis of Cellulitis (a bacterial infection of your skin and the tissue beneath your skin) of the right lower limb and MRSA of the right foot wound. Record review of Resident #36 doctor's order dated 12/22/2023 revealed that Resident was ordered Contact Isolation for MRSA of the right foot wound. Contact Isolation was ordered as a measure to prevent the spread of; people who are infected with MRSA often are placed in isolation as a measure to prevent the spread of the infection. Observation on 01/09/23 at 1:00pm, of wound care provided to the resident by the Wound Nurse, who did not implement Contact Isolation Precautions for Resident #36 while providing wound care the resident. The Wound Nurse entered the resident room without donning a gown. After entering Resident #36's room, the Wound Care Nurse donned gloves but fail to donn a gown prior to providing wound care to Resident #36. The Wound Care Nurse changed Resident #36's wound dressing and had direct contact with Resident #36 without implementing the recommended contact precautions of wearing a gown. Interview on 01/09/2024 at 2:45pm, with the Wound Care Nurse, the Wound Care Nurse confirmed that Contact Isolation Precautions should be maintained for Resident #36. The Wound Care Nurse stated Resident #36 was on Contact Isolation for MRSA of the wound. The Wound Care Nurse stated that she was knowledgeable of the facility's infection control policy. The Wound Care Nurse was able articulate knowledge related to what PPE (gown and gloves) should be used when providing care for Contact Isolated residents. The Wound Care Nurse stated that when the donning of PPE is not implemented infection could spread to other residents and staff. Interview on 01/09/2024 at 3:00pm, CNA K acknowledged that she had been educated on infection control and transmission-based precautions. CNA K stated that when the donning of PPE is not implemented infection could spread to other residents and staff in the facility. Interview with the DON on 01/09/2024 at 3:10pm, who stated that she did not know why the Wound Care Nurse did not implement Contact Isolation Precaution and donn proper PPE when providing care to Resident #36. The DON stated that Resident #36 was on Contact Isolation Precaution for MRSA of the wound. The DON stated that the Wound Care Nurse should have donned PPE (gown and gloves) prior to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675321 If continuation sheet Page 10 of 11 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 675321 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502 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 entering the resident's room and when she provided wound care. The DON stated that staff had been trained on infection control and transmission-based precautions. The DON stated that when the donning of PPE is not implemented infection could spread to other residents and staff. Interview on 01/10/2024 at 10:30am, Resident #36 who stated that the Wound Care usually would wear gloves when providing wound care, but the resident stated that he did not ever recall the Wound Care Nurse wearing a gown when providing wound care. Resident #36 stated was not able to verbalize why Contact Isolation Precaution and PPE (gown and gloves) should be worn prior to providing wound care. Interview on 01/10/2024 at 11:00am, with the Infection Preventionist, who stated that staff had been trained on infection control and transmission-based precautions. The Infection Preventionist stated that Resident #36 was on Contact Isolation Precaution for MRSA of the wound. The Infection Preventionist, stated that the Wound Care Nurse should have donned PPE (gown and gloves) prior to entering the resident's room and when she provided wound care. The surveyor requested the facility policy related to Infection Control and Transmission Based Precautions. The Infection Preventionist stated that when the donning of PPE is not implemented infection could spread to other residents and staff. Record review of the facility's provided policy, titled Infection Control Policies and Procedure, Subject: MRSA, dated 06/2019, indicated .healthcare workers hands are washed before and after contact with resident glove and gowns are worn mask/goggles are used whenever there is risk of splash According to the Center Disease Control and Prevention, MRSA is spread through direct contact with an infected person or animal. MRSA can survive on surfaces for hours, sometimes weeks. You can pick up the bacteria by touching or sharing contaminated items. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675321 If continuation sheet Page 11 of 11

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Citations

5 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.

0640GeneralS&S Dpotential for harm
F640 - Automated data processing requirement-
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
0641GeneralS&S Dpotential for harm
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
0553GeneralS&S Dpotential for harm
F553 - The right to participate in the development and implementation of his or her
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
0657GeneralS&S Dpotential for harm
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
0880GeneralS&S Dpotential for harm
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 January 10, 2024 survey of Paradigm at Faith Memorial?

This was a inspection survey of Paradigm at Faith Memorial on January 10, 2024. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Paradigm at Faith Memorial on January 10, 2024?

Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment."

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

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Health inspection·January 10, 2024