Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0610
Respond appropriately to all alleged violations.
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 ensure that all alleged violations involving abuse, neglect,
exploitation or mistreatment which included injuries of unknown sources and misappropriation of resident
property in accordance with state law through established procedures and the facility failed to report the
results of all the investigations to the administrator or his or her designated representative and to other
officials in accordance with the state law which included to the survey agency within 5 working days of the
incident and if the alleged violation was verified appropriate corrective action must be taken for 1 of 4
residents (CR #1) reviewed for abuse and neglect. -The facility failed to report results of a self-reported
incident when CR #1 had a fall with injury and was sent to the hospital on [DATE].This failure could place
residents involved in abuse incidents at risk of continued abuse, further injury, pain, and physical and
emotional distress. Record review of CR#1's face sheet dated 11/20/2025 reflected an [AGE] year-old
female who was admitted to the facility on [DATE]. Record review CR#1's face sheet had diagnoses of
unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety,
muscle weakness, hypertension (high blood pressure), insomnia (difficulty with sleeping), hyperlipidemia
(high fat content in the blood), abnormal findings of blood chemistry, anxiety disorder (chronic excessive
worry), Alzheimer's disease (a progressive brain disease causing memory loss), acute kidney failure and
unspecified anemia (low iron in the blood).Record review of CR#1's Comprehensive Care Plan dated
11/20/2025 reflected that on 7/28/25 CR#1 had an unwitnessed fall with left hip intertrochanteric fracture of
left femur.Record review of CR#1's clinical record during her stay in the facility reflected there was not a
provider investigation report sent to the state survey agency.Record review of CR #1's progress notes for
July 2025:-07/28/2025 at 2:48am, CR#1 was noted wandering along the corridor and night staff attempted
to redirect her. CR #1 was given Hydroxyzine 25 mg for anxiety and pain medication for pain. CR #1 laid in
bed afterward.-07/28/2025 at 8:36am, CR #1 was noted as having a fall on at 4:30am, witnessed and
without head injury. CR #1's medication was reviewed and RP was notified.-0728/2025 at 10:50am, CR #1
had 2 x-rays completed which came back with acute left hip fracture. CR #1's MD notified and the MD gave
orders for CR#1 to be sent out to the hospital.Record review of CR #1's x-rays dated 07/28/2025, she had
acute left hip fracture at the intertrochanteric region (upper leg).Record review of CR #1's hospital visit
dated 07/28/2025, she was admitted with leg pain and unable to walk after the fall. Imaging showed CR#1
had a fracture with a negative brain scan. CR #1 was admitted for further evaluation and
medication.Interview on 11/29/2025 at 10:58am, the DON said the facility had taken steps before the fall on
07/28/2025 to transfer CR #1 to another facility with a locked unit due to wandering. The DON said that was
when the new Administrator was taking over and was getting orientation, so she did not know if the
previous Administrator had sent the 5-day investigation in or not. But the new Administrator will include the
DON in submissions so that the Administrator and DON will be on the same page. Interview with the
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 3
Event ID:
676064
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
676064
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paradigm at Katy
1480 Katy Flewellen
Katy, TX 77494
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 0610
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Administrator on 11/20/ 2025 at 1:44pm, he said he was not the Administrator at the time and was not
notified or aware about the fall on 07/28/2025. He found the initial report and facility investigation but could
not find the 5-day investigation. The Administrator said if the investigation report was not sent in, there was
a possibility that the investigation would not be completed. If the investigation was not done, then an issue
related to CR #1's fall could have remained unaddressed. The Administrator said the goal was to focus on
taking care of residents.Record review of facility's Abuse/ Neglect & Exploitation Policy dated 04/2024
reflected the facility will report all alleged violations, involving abuse, neglect, exploitation or mistreatment
including injuries of unknown source to the administrator or a designee and reports any alleged abuse,
neglect, exploitation or mistreatment including injuries of unknown source should also be reported to other
officials including to the state agency in accordance with applicable state law.
Event ID:
Facility ID:
676064
If continuation sheet
Page 2 of 3
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
676064
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Paradigm at Katy
1480 Katy Flewellen
Katy, TX 77494
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
Based observation, interview, and record review, the facility failed to 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 infections for one (Hallway A) of four
hallways observed for infection control. -CNA K left her hooded jacket and eyeglass case of the clean linen
cart in Hallway A.This failure could place the residents at risk of cross-contamination and development of
infection. During an observation and interview with RN C of a clean linen cart on Hallway A on 11/19/2025
at 12;19pm, there was an eyeglass case laying directly on top of a black zip-up jacket which was laying on
top of the green mesh covering of the clean linen cart. The wheeled cart contained folded linen sheets and
briefs inside the mesh cover. RN C said those items should not have been there and that it was an infection
control issue. Interview with CNA B on 11/19/2025 at 1:55pm, she said she was one of the CNAs working
on Hallway A but was not the person who put the jacket on the cart. CNA B said the jacket and eyeglass
case should not have been there and that could be an infection control issue. Personal items could be
placed in a locker or purse. Interview with CNA K on 11/19/2025 at 2:00pm, she said she was giving a
resident a bed bath and then her sleeves of her jacket got wet, so she took it off and placed it along with
her eyeglass case on the clean linen cart because she had to get back to the resident. CNA K apologized
and said she shouldn't have done that and that it was an infection control issue. CNA K said she should
have put it up somewhere else. Interview with the ADON on 11/20/2025 at 1:39pm, he said he was also the
Infection Preventionist at the facility. The ADON said everything in the cart was for residents and that staff
items like the jacket and eyeglass case should not have been on the cart. The facility had halls with major
infections and if those items came into contact with staff, infections could spread to residents and vice
versa. Interview with the Administrator on 11/20/2025 at 1:44pm, he said that the staff personal items
should not have been on the cart. He said it would have been hard to say if the jacket would have caused
an infection control issue. If the jacket was wet, then it might be an infection control issue, but he did not
know the state of the jacket on the linen cart.Interview with the DON on 11/20/2025 at 3:01pm, she said the
clothing items should not have been on the cart. She was going to do another audit on CNA K and do some
re-training. The DON said a negative outcome of the clothing item on the clean linen cart could be infection
control and that the facility needed to maintain their isolation protocol.Record review of the facility's policy
on Infection Control last revised on 6/2024 read in part, The Facility is dedicated to maintaining a safe and
healthy environment by implementing an effective infection control program that adheres to state and
federal regulations . Environmental Safety .The cleanliness and hygiene standards within The Facility are
paramount for effective infection control practices .Includes: regular disinfection of high-touch surfaces,
proper handling and disposal of contaminated materials, and maintenance of optimal ventilation and air
quality.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676064
If continuation sheet
Page 3 of 3
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Back to topCitations
2 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.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
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 November 20, 2025 survey of Paradigm at Katy?
This was a inspection survey of Paradigm at Katy on November 20, 2025. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Paradigm at Katy on November 20, 2025?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Respond appropriately to all alleged violations."
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.