676064
12/15/2025
Paradigm at Katy
1480 Katy Flewellen Katy, TX 77494
F 0919
Make sure that a working call system is available in each resident's bathroom and bathing area.
Level of Harm - Minimal harm or potential for actual harm
Based on observations, interviews and record review, the facility failed to ensure the facility was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 1 call light systems reviewed for resident call system in that: The facility failed to provide a reliable and effective nurse call system and timely staff response.This failure could result in delayed staff response and placed residents at risk of respiratory compromise and injury related to delayed call light response. Interviews on 12/13/2025 at varies time between 1:00PM - 3:00PM with direct care staff (CNA D, Staff J, Nurse A, RT A) stated that the facility nurse call system does not provide audible alerts which could be heard and relied on staff visually monitoring hallway lights. Staff stated that if they were in resident rooms or other areas, they might not see the activated call lights promptly. Staff stated that the residents and staff had previously complained about the call light system and the system had been repaired (September/2025) but audible alerts could not be heard. Staff stated this limited staff ability to monitor and respond to resident calls for assistance and could have placed residents at risk for delayed response to care needs. Staff denied notifying the administrator and DON of the inability to hear audible alerts. Staff denied having knowledge of any residents who had sustained injury related to delayed call light response times. Interview on 12/13/2025 at 3:30PM, the Maintenance staff stated he was not informed of ongoing concerns or complaints related to the nurse call system's effectiveness or delayed response times reported by residents.Interview on 12/13/2025 at 3:40PM, the DON stated she was not aware of resident or staff concerns regarding delayed nurse call light response times or ineffectiveness of the nurse call system.Interview on 12/13/2025 at 12:53PM, the Administrator stated he was not informed of staff or resident concerns related to the nurse call system. The Administrator further stated the nurse call system had been repaired in September 2025 and indicated he believed the system was functioning as intended at that time.Observation on 12/13/2025, the surveyor tested the nurse call system in residents (Resident #1 and Resident #2) rooms, and the system activated a visual hallway light, with no audible alert in the hallway, and a low audible alert at the nurse station. The activated 400 hallway light for Resident #2 was not visible from the nurse station. Record review of maintenance log, revealed no repairs made to call light system during the 30-day look back period. Record review on of repair invoice on 12/16/2025 revealed call light system had been repaired with audible sound on 12/16/2025. Interviews on 12/16/2025 at varies time between 2:00PM - 4:00PM with direct care staff (Nurse B, RT E) stated that the facility nurse call system provided audible alerts which could be heard and relied on by staff. Record review revealed in-service and training documentation related to abuse and neglect, and call light response had been provided by the facility 12/2025. Review of the facility's current policy not dated, titled Call Lights reflected:The Facility will provide a call light system that is accessible, functional, and responsive to meet the needs of the residents. Call lights will be placed within
Residents Affected - Some
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676064
676064
12/15/2025
Paradigm at Katy
1480 Katy Flewellen Katy, TX 77494
F 0919
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
reach of the resident's bed or sitting area in the resident's room. Response Staff are required to respond to activated call lights in a timely manner. While the specific response time will vary, staff will respond in a manner to address the residents' needs. Once needs are addressed, turn the call light off. Functionality Call lights will be in working order. Call lights will be monitored routinely to assess functionality. Accommodations The Facility will evaluate residents for potential accommodation for alternative call light systems when they have any limitations that affect their ability to use a standard call light.
676064
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