Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Paradigm At Katy during CMS and state inspections, most recent first.
A resident with COPD and heart failure experienced shortness of breath and activated the call light for help, but staff did not respond due to an ineffective nurse call system that lacked audible alerts. The resident called 911 for assistance, and EMTs confirmed the system only provided a visual alert not visible from the nurse station. Staff and residents had previously reported issues with the call system, but these concerns were not communicated to facility leadership, resulting in delayed response to care needs.
A resident with respiratory needs was unable to receive timely staff assistance due to a malfunctioning nurse call system that only activated a visual hallway light, which was not visible from the nurse station and did not provide an audible alert. Staff relied on visually monitoring hallway lights, and concerns about the system's effectiveness were not communicated to facility leadership. The resident ultimately called 911 for help when staff did not respond to the activated call light.
A resident with dementia and multiple comorbidities experienced an unwitnessed fall resulting in a hip fracture. Although the incident was documented and the resident was sent to the hospital, the facility did not submit the required 5-day investigation report to the state survey agency as mandated by policy and law. Interviews indicated confusion during an administrative transition contributed to the reporting failure.
A CNA placed her personal jacket and eyeglass case on a clean linen cart containing folded linens after her sleeves became wet while assisting a resident with a bed bath. This action was observed and confirmed by staff, including an RN, ADON, Administrator, and DON, as a violation of infection control policy, which requires personal items to be kept separate from clean resident supplies.
Three residents did not receive timely assistance with ADLs, including incontinent care and personal grooming. Two residents were left in soiled briefs and bedding for extended periods, and another had long, untrimmed toenails despite staff awareness of the issue. Staff interviews revealed missed care rounds, high workloads, and confusion over responsibilities, resulting in unmet hygiene and grooming needs.
The facility did not provide meaningful, person-centered activities as required, particularly on weekends, with observations and resident interviews confirming that scheduled activities were not conducted and residents were left without engagement. Staff interviews and review of the activities calendar further supported that activities were either not offered or did not meet residents' interests, resulting in a lack of support for residents' physical, mental, and psychosocial well-being.
A resident with significant medical needs, including an indwelling catheter, was found with an exposed foley catheter bag and visible urine, contrary to facility policy requiring privacy covers. Nursing staff and the DON confirmed that privacy bags are mandated and that staff are regularly trained on this requirement, but the privacy bag was not replaced after catheter care, resulting in a lapse in maintaining the resident's dignity.
A resident with sepsis and heart failure, who required oxygen therapy, did not have oxygen use addressed in her comprehensive care plan. The omission was confirmed by staff review of records and interviews, revealing that the care plan lacked measurable objectives and interventions for oxygen until after the issue was identified.
Two bottles of hair products belonging to former residents were found unsecured on a dresser in a resident's room. The resident was totally dependent on staff for care and unable to communicate. Staff interviews confirmed that such items should be labeled and stored in drawers to prevent cross-contamination and access by wandering residents, but this protocol was not followed.
A CNA did not follow proper perineal care procedures for a female resident who was incontinent, failing to separate the labia and adequately clean the area during incontinent care. The issue was identified during an observation, and additional cleaning was required to remove fecal matter. The resident had multiple medical conditions and required assistance with daily living activities. Facility policy and staff interviews confirmed that the correct procedure was not followed, increasing the risk of infection.
A resident with a gastrostomy tube was administered high-protein tube-feeding formula at a rate of 56ml/hr instead of the physician-ordered 55ml/hr. This discrepancy was identified through observation, record review, and staff interviews, which revealed that the feeding machine settings were not properly verified and adjusted according to the order. Staff acknowledged the error and noted that CNAs may have inadvertently changed the settings during care, and the responsible RN did not confirm the correct rate as required by facility policy.
A resident's medications, including Ipratropium and Budesonide, were found on a medication cart after the resident had been discharged. An LVN confirmed these medications should have been removed to prevent administration to other residents, and the DON stated that facility policy requires immediate removal and secure storage of discontinued medications.
A medication cart was found to contain a Lidocaine vial with injection marks and no date of opening, contrary to facility policy requiring multi-dose vials to be dated. The LVN assigned to the cart stated she was not the one who opened the vial, and the DON confirmed the vial should have been dated.
A deficiency was cited when the side door of a dumpster was found open and half-full of trash, contrary to facility policy requiring dumpsters to remain closed. Staff interviews confirmed that all departments use the dumpster and acknowledged it should be kept closed to prevent pest entry and infection control issues.
Surveyors identified infection control deficiencies involving two residents: one had Foley catheter tubing resting on a fall mat and at times on the floor, despite staff training and facility policy requiring proper placement to prevent infection; another resident's room contained hair products labeled for other residents, contrary to protocols for labeling and storing personal hygiene items to prevent cross-contamination.
A deficiency was identified when a CNA improperly repositioned a fully dependent male resident with complex medical needs by pulling his arm to move him in bed, rather than following proper procedures. The incident was witnessed on video, and both involved CNAs acknowledged the technique was inappropriate. The facility's policy required individualized and documented repositioning, which was not followed in this case.
The facility failed to maintain an effective infection control program, leading to the spread of Candida auris among residents. Staff were observed not using PPE or performing hand hygiene when interacting with residents on contact precautions. Interviews revealed gaps in infection control practices, with the new Infection Preventionist unaware of the number of affected residents and lacking a clear mitigation plan. The administration also showed a lack of oversight, contributing to the ongoing outbreak.
A facility's call light system was non-functional for five months, leaving residents without a reliable way to call for help. One resident, who was quadriplegic and on mechanical ventilation, experienced a delay in care, leading to a 911 call. Other residents faced similar challenges due to inadequate alternative devices.
A resident with complex medical needs experienced a significant change in condition, including shortness of breath and high fever, during the night shift. Despite family members calling the facility multiple times, staff did not respond or provide necessary interventions. The resident's condition was not addressed until EMS arrived, highlighting a failure in monitoring and communication.
A facility failed to create a comprehensive baseline care plan for a newly admitted resident with complex medical needs, including quadriplegia and a tracheostomy. The care plan did not address essential areas such as communication methods, tracheostomy care, and nighttime anxiety management, despite these being critical to the resident's care. Interviews with staff revealed that the baseline care plan was not adequately updated to reflect the resident's needs, contrary to facility policy.
The facility failed to ensure staff had gloves readily available, leading to care delays and increased infection risks. Despite claims of sufficient supplies, interviews revealed frequent struggles to access gloves, exacerbated by a storm and unpaid invoices. Residents reported delays in care due to supply issues, highlighting a disconnect between ordering, payment, and availability.
The facility failed to provide timely emergency medical treatment to two residents with end-stage renal disease. One resident missed dialysis due to a problematic catheter and was not promptly transferred to the hospital, resulting in his death. The second resident required a blood transfusion but faced delays in transportation, with no specific dialysis interventions in his care plan. Staff interviews revealed communication issues and a lack of urgency in addressing the residents' medical needs.
A resident with end-stage renal disease did not receive timely dialysis due to a malfunctioning catheter and poor communication between the facility and dialysis center. The resident missed several treatments, leading to fluid overload and eventual death. Staff failed to act urgently, scheduling non-emergency transport instead of immediate medical intervention.
The facility failed to investigate and report alleged violations involving infection control, physical environment, and abuse for several residents. The Administrator misunderstood the reporting requirements, believing that an email to TULIP sufficed instead of completing the required 3613-A PIR form. The Regional Nurse was unaware of any self-reports other than a recent abuse allegation, indicating a lapse in communication and adherence to the facility's policy.
A resident with a tracheostomy independently changed her inner cannula without sterile technique, and the facility failed to notify her physician or document the incident as required by policy. The resident, who had complex medical conditions, reported changing her cannula multiple times a week without staff assistance. Interviews revealed inadequate training and communication among staff regarding tracheostomy care responsibilities.
The facility failed to maintain the call light system in shower room [ROOM NUMBER] in safe operating condition, with exposed wires and no emergency call light cord in shower stall #2. Staff were unaware of the issue, and no repair requests were documented. A resident confirmed noticing the exposed wires for several months and avoided using the stall out of fear of electrocution.
The facility failed to ensure a working call system in shower stall #2 in shower room [ROOM NUMBER], leading to exposed wiring and an inoperable call bell. Staff were unaware of the issue, and no maintenance requests were logged despite the problem being present for several months. A resident with a history of falls and ventilator dependence had noticed the issue, highlighting a significant lapse in maintenance and reporting procedures.
The facility's 200-Hall restrooms lacked a functioning call system, with observations showing that call light cords did not activate exterior lights and emergency bells were faint. Staff interviews confirmed the bells were not loud enough, and records indicated the call system had been problematic since before January 2023. The current system was deemed beyond repair, necessitating replacement.
A resident with multiple health issues, including diabetes and kidney failure, experienced a significant change in condition, including vomiting and high blood sugar levels. The facility failed to notify the physician and the resident's representative, and insulin was discontinued without proper oversight. The resident was eventually sent to the hospital and died. Interviews revealed a lack of communication and documentation among staff.
A resident with multiple health issues, including diabetes, experienced a change in condition that was not adequately addressed by the facility. The resident had high blood glucose levels and began vomiting, but the facility failed to monitor and manage these symptoms according to the care plan. Insulin was erroneously discontinued, and there was a delay in sending the resident to the hospital, leading to hospitalization and eventual death.
A resident with diabetes and multiple health conditions was left without insulin due to a nurse's error in discontinuing both insulin NPH and Lispro, despite only Lispro being ordered to stop. The resident experienced high blood sugar levels for several days, and the facility failed to notify the physician or take corrective action. This oversight led to the resident's hospitalization and subsequent death.
Failure to Provide Timely Assistance Due to Ineffective Nurse Call System
Penalty
Summary
The facility failed to provide timely assistance to a resident with a history of COPD, congestive heart failure, and anxiety when she experienced shortness of breath and required staff assistance. The resident activated her call light for help but did not receive a response from staff, leading her to call 911 for emergency assistance. Upon arrival, EMTs found that the nurse call system only activated a visual light above the resident's door, with no audible alert in the hallway or at the nurse station, making it difficult for staff to be aware of calls for help. Interviews with staff revealed that the nurse call system had been previously repaired, but the audible alerts were still not functioning, and staff relied solely on visual cues, which were not always visible from the nurse station or other areas. Staff and residents had previously complained about the call light system, but these concerns were not communicated to the administrator, DON, or maintenance staff. The lack of an effective alert system limited staff's ability to monitor and respond promptly to resident needs, particularly for those with respiratory conditions. The resident's care plan included interventions for monitoring respiratory status and responding to signs of distress, but these were not effectively implemented due to the call system's deficiencies. The facility's policy required a functional and responsive call light system, but observations and interviews confirmed that the system did not meet these requirements at the time of the incident. There was no evidence of a specific policy for residents with respiratory needs, and maintenance logs did not reflect any repairs to the call light system during the relevant period.
Failure to Provide Functional Nurse Call System for Resident Assistance
Penalty
Summary
The facility failed to ensure that a reliable and effective nurse call system was available and functional for residents, specifically impacting a resident with significant respiratory needs. The call system in the resident's room and bathroom only activated a visual hallway light, with no audible alert to the nurse station or hallway, and the hallway lights were not visible from the nurse station. Staff interviews confirmed that the system did not provide audible alerts and that staff relied on visually monitoring hallway lights, which could not always be seen if staff were in other rooms or areas. Staff and residents had previously complained about the call system, but these concerns were not communicated to the administrator, DON, or maintenance staff. A resident with chronic respiratory conditions, including COPD and respiratory failure, experienced shortness of breath and attempted to call for assistance using the call light system. No staff responded, leading the resident to call 911 for help. Emergency medical personnel arrived and found that the nurse call system did not provide adequate notification to staff, as only a light above the door was activated without an audible alert. The EMTs had to contact the facility's front desk to alert staff to the resident's needs. The resident reported feeling that her oxygen supply was inadequate at the time and could not recall staff responding to her activated call light. Observations by the surveyor confirmed that the nurse call system in multiple rooms only activated a visual hallway light, with no audible alert in the hallway and only a low audible alert at the nurse station. Maintenance logs showed no repairs to the call light system in the 30 days prior to the incident, and the administrator and DON were unaware of any ongoing issues. Staff interviews indicated that the lack of an effective call system limited their ability to respond promptly to residents' needs, particularly for those with urgent medical conditions.
Failure to Report and Investigate Resident Fall with Injury
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment—including injuries of unknown source—were reported and investigated in accordance with state law and facility policy. Specifically, for one resident with multiple diagnoses including dementia, Alzheimer's disease, and muscle weakness, there was an unwitnessed fall resulting in a left hip fracture. The clinical record and progress notes indicated that the fall was documented, the resident was assessed, and sent to the hospital for further evaluation and treatment. However, there was no evidence that a provider investigation report or the required 5-day investigation report was submitted to the state survey agency as mandated. Interviews with the DON and the current Administrator revealed that the transition between administrators contributed to the lack of clarity regarding whether the required investigation report was submitted. The DON was unsure if the previous Administrator had completed the process, and the current Administrator could not locate the 5-day investigation report in the facility's records. The facility's own policy required reporting all such incidents to the administrator or designee and to the state agency, but this was not followed in this case.
Personal Items Placed on Clean Linen Cart Breaches Infection Control Protocol
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) placed her personal hooded jacket and eyeglass case on top of a clean linen cart in Hallway A, which contained folded linen sheets and briefs. The CNA reported that her jacket sleeves became wet while giving a resident a bed bath, so she removed the jacket and placed it, along with her eyeglass case, on the clean linen cart before returning to care for the resident. This action was observed by a registered nurse (RN), who confirmed that personal items should not be on the clean linen cart and identified it as an infection control issue. Other staff, including another CNA, the Assistant Director of Nursing (ADON), the Administrator, and the Director of Nursing (DON), all acknowledged during interviews that personal items should not be placed on the clean linen cart and that this practice could present an infection control concern. The facility's infection control policy, last revised in June 2024, emphasizes maintaining a safe and healthy environment through effective infection control practices, including proper handling of materials and environmental safety. The incident was identified during observation, interview, and record review, and it was noted that the facility had residents with major infections on the halls, increasing the importance of strict adherence to infection control protocols. The presence of personal items on the clean linen cart was recognized by multiple staff members as a breach of these protocols.
Failure to Provide Timely ADL Assistance and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs) for three residents who were unable to perform these tasks independently. For two residents, staff did not provide timely incontinent care. One resident, a male with a history of ventilator dependence, hypertension, and gastrostomy, was found with a saturated and soiled brief, a strong ammonia odor in the room, and a soaked draw sheet. Staff interviews revealed that required two-hour rounding and incontinent care were not performed as scheduled, with the CNA citing being overburdened with other residents and tasks. The nurse and unit manager confirmed that the resident was at risk for skin breakdown due to the lack of timely care. Another resident, a female with diagnoses including colon cancer, hypertension, atrial fibrillation, and cognitive communication deficit, also did not receive timely incontinent care. She reported feeling wet and neglected, and observation confirmed her brief was saturated with urine and bowel movement, with soiling extending to the draw sheet. Staff interviews indicated that the resident had not been changed for several hours, and the CNA responsible stated she was doing her best given her workload. The DON and medical director acknowledged that the lack of timely care placed the resident at risk for skin maceration and breakdown. A third resident, a female with ventilator dependence, tracheostomy, hypotension, and cognitive communication deficit, was observed to have long, classified toenails. Staff interviews revealed that aides had reported the issue to nursing staff weeks prior, but no action was taken to address the toenails. There was confusion among staff regarding responsibility for toenail care, especially after the resident was placed on hospice care. The DON, unit manager, and ADON all acknowledged the risk posed by the long toenails, but there was no documentation or follow-up to ensure the resident received appropriate grooming and personal hygiene.
Failure to Provide Meaningful Activities for All Residents
Penalty
Summary
The facility failed to provide activities that met the interests and supported the physical, mental, and psychosocial well-being of all residents reviewed for activities. Observations on both a Sunday and the following Monday revealed that no activities were visible in the activity area during the survey period. Interviews with residents indicated that there were no weekend activities, and the activities listed on the posted calendar were not actually provided. Residents reported that the Activity Director was present on Sundays but remained in her office, and that the activities listed on the calendar were not reflective of their actual experiences. Residents expressed feelings of boredom and frustration, noting that passive options like watching TV in their rooms were not meaningful activities, and some activities listed, such as bird watching, were not genuinely offered. Interviews with the Activity Director and other staff confirmed that many scheduled activities were not conducted, with the Activity Director attributing this to residents' refusals or lack of interest. However, residents disputed this, stating that activities were not offered as described. Review of the activities calendar showed limited and repetitive options on weekends, such as family visits, individual activity sheets, and watching TV, with minimal engagement opportunities. The facility's policy required meaningful, person-centered activities, but these were not observed or reported by residents during the survey period.
Failure to Maintain Resident Dignity by Not Covering Foley Catheter Bag
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including functional quadriplegia, dementia, and an indwelling urinary catheter, was observed in bed with his foley catheter bag exposed and urine visible. The resident was unable to respond to verbal stimuli at the time of observation. Facility policy and staff interviews confirmed that catheter bags are required to be stored in privacy bags to maintain resident dignity, and this expectation was reinforced through regular in-service training for nursing staff. Despite these policies and trainings, the resident's catheter bag was not covered, and staff acknowledged that it was their responsibility to ensure privacy bags were used. The lack of a privacy bag was attributed to the previous cover being discarded and not replaced after catheter care. Multiple staff, including LVNs, RNs, and the DON, confirmed the requirement for privacy covers and their roles in ensuring compliance, but the deficiency occurred due to a lapse in following established procedures.
Failure to Include Oxygen Use in Resident's Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's needs, specifically omitting the resident's oxygen use as a focus area. Record review showed that the resident, a cognitively intact female with diagnoses including sepsis and heart failure, required substantial to maximal assistance with activities of daily living and used oxygen as a special treatment. Despite this, her comprehensive care plan did not include any interventions or objectives related to oxygen use. Interviews with facility staff confirmed that there was no care plan for oxygen use in either of the electronic medical record systems until it was added after the deficiency was identified. The MDS Coordinator acknowledged the omission, and the DON emphasized the importance of comprehensive care plans and MDS assessments in ensuring correct and safe care. Facility policy requires the interdisciplinary team to develop a comprehensive care plan within seven days of completing the assessment, but this was not followed in this case.
Unsecured Personal Care Products Found in Resident Room
Penalty
Summary
A deficiency was identified when two bottles of hair products, belonging to former residents, were found unsecured on top of a dresser in a resident's room. The resident in question was a female with significant medical conditions, including Type 2 Diabetes Mellitus, Dementia, Dysphagia, a traumatic subdural hemorrhage, and a tracheostomy. She was totally dependent on staff for all activities of daily living and was rarely or never understood, as indicated by her MDS assessment. The facility census also indicated that five residents were ambulatory, increasing the risk of access to unsecured items. During observation, the resident was unresponsive and resting in bed, with the hair product bottles clearly visible and accessible. Staff interviews revealed that personal hygiene products should be labeled, sealed, and stored in residents' drawers to prevent cross-contamination and reduce risk to wandering residents. However, the bottles were not stored according to these protocols, and the facility did not have a specific accident/hazards policy in place. The facility's Resident Rights policy emphasized the need for a safe environment, but this was not adhered to in this instance.
Failure to Provide Proper Perineal Care During Incontinent Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide appropriate perineal care to a female resident who was incontinent of bowel and bladder. During an observation, the CNA did not separate the resident's labia while performing incontinent care, which was contrary to the facility's policy and standard infection control practices. The surveyor intervened before the CNA closed the clean brief, prompting the CNA to properly separate the labia and continue cleaning, at which point fecal matter was still present and required additional wiping to achieve cleanliness. The resident involved had a history of malignant neoplasm of the colon, hypertension, atrial fibrillation, and a cognitive communication deficit, but was assessed as cognitively intact and required assistance with activities of daily living. Interviews with the CNA, unit manager, and director of nursing confirmed that the expected procedure was not followed, as the CNA should have separated the labia and cleaned from front to back using a clean wipe for each stroke. The facility's policy on perineal care also specified these steps to reduce infection risk and promote skin integrity.
Failure to Follow Physician Orders for Enteral Feeding Administration
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition via a gastrostomy tube was administered the prescribed amount of high-protein tube-feeding formula as ordered by the physician. The physician's order specified that the resident should receive 55ml per hour of a 1.5 calorie formula continuously for 22 hours each day. However, observation and record review revealed that the feeding machine was set to deliver 56ml per hour instead of the ordered 55ml per hour. The resident in question had significant medical conditions, including acute and chronic respiratory failure, moderate protein-calorie malnutrition, and dehydration, and was dependent on tube feeding for more than half of his caloric intake. The care plan for the resident emphasized the importance of following physician orders for tube feedings to prevent complications such as aspiration, dehydration, and nutritional compromise. Despite this, the medication administration record and direct observation confirmed that the feeding was not administered as ordered. Interviews with facility staff, including the DON, Administrator, and the responsible RN, confirmed that the deviation from the physician's order was not intentional and may have resulted from CNAs stopping and starting the feeding machine during care, potentially altering the settings. The RN acknowledged responsibility for verifying the correct administration rate and was unaware of the discrepancy until it was brought to his attention. Facility policy required staff to review and implement physician orders accurately and document any clarifications, but this was not followed in this instance.
Failure to Remove Discharged Resident's Medications from Medication Cart
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not removing or disposing of medications belonging to a discharged resident. During an observation of a medication cart, it was found that medications labeled for a resident who had already been discharged remained on the cart, including Ipratropium .02% solution, Ipratropium .02% nebulizer solution, and Budesonide inhalation suspension. The nurse interviewed confirmed that these medications should have been removed from the cart upon the resident's discharge to prevent them from being administered to another resident. The Director of Nursing stated that medications may remain on the cart for up to 24 hours if a resident is expected to return, but should be disposed of if the resident does not come back. Facility policy requires that discontinued or discharged residents' medications be immediately removed from active supply and stored separately until destroyed. The failure to follow these procedures resulted in the continued presence of the discharged resident's medications on the active medication cart.
Undated Lidocaine Vial Found on Medication Cart
Penalty
Summary
A deficiency was identified when a medication cart (Cart B) was found to contain a vial of Lidocaine Hydrochloride injection with visible injection marks on the seal and no date indicating when it was opened. During observation, it was noted that the vial was not labeled with the date of opening, as required by facility policy and professional standards. The LVN responsible for the cart stated that she would have dated the vial if she had opened it, but she was not the person who did so. The DON and Corporate Nurse confirmed that the vial should have been dated to ensure proper tracking of the medication's shelf life. Review of the facility's policy confirmed that multi-dose vials must be labeled with the date opened.
Improper Disposal of Garbage Due to Open Dumpster Door
Penalty
Summary
A deficiency was identified when the facility failed to properly dispose of garbage and refuse by leaving the side door of Dumpster A open, as observed during a survey. The dumpster was found half-full of trash with the left-side sliding door open. Multiple staff members, including the dietary supervisor, dietary manager, housekeeping supervisor, and the administrator, acknowledged during interviews that the dumpster should remain closed to prevent access by animals, pests, and unauthorized individuals, as well as to avoid potential infection control issues. Review of the facility's waste disposal policy confirmed that dumpsters are required to be closed at all times to prevent disease transmission and pest attraction.
Infection Control Deficiencies Related to Foley Catheter Care and Personal Hygiene Product Storage
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for two residents. For one resident with functional quadriplegia, a gastrostomy, and a tracheostomy, observations revealed that his Foley catheter tubing was resting on his fall mat and at times on the floor. Nursing staff, including LVNs and RNs, acknowledged that the tubing should not be on the floor or on the fall mat, as this does not follow infection control protocols. Staff interviews indicated that the resident's bed being in the lowest position made it difficult to keep the tubing off the floor, but it was still the staff's responsibility to ensure proper placement. Facility in-service records confirmed that staff had received training on Foley catheter care, including the importance of keeping tubing off the floor and allowing for gravity drainage. For another resident who was totally dependent on staff for activities of daily living and had diagnoses including diabetes, dementia, and a tracheostomy, two bottles of hair products labeled with other residents' names were found on her dresser. Staff interviews confirmed that personal hygiene products should be labeled and stored in a way that prevents cross-contamination, such as in sealed bags or drawers. The presence of these items in the resident's room was recognized by staff as a potential source of cross-contamination between residents' personal items. Facility policy reviews showed that there were established procedures for catheter care and infection control, including the prevention, identification, and control of infections. However, the observed practices did not align with these policies, as evidenced by the improper handling of catheter tubing and the storage of personal hygiene products belonging to other residents in a resident's room.
Improper Repositioning and Inadequate Supervision of Dependent Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) improperly repositioned a dependent male resident with multiple complex medical conditions, including acute and chronic respiratory failure, end stage renal disease, a tracheostomy, and a history of being fully dependent for activities of daily living. The resident was observed on video lying sideways in bed with his head hanging off the edge. CNA A entered the room and, without assistance, pulled the resident by his left arm to reposition him toward the center of the bed. Another CNA entered the room during the incident but did not intervene in the repositioning process. Interviews with staff and the resident's family member confirmed that the resident was unable to move himself and was at risk of falling from the bed. The family member reported witnessing the incident via a camera in the resident's room and described the repositioning as rough and inappropriate, though no bruising was observed. Both CNAs involved acknowledged that the repositioning technique used was not appropriate and did not follow proper procedures, with CNA A stating she acted out of fear that the resident would fall. CNA A also admitted she had not received recent training on proper repositioning techniques. A review of the facility's policy on turning and repositioning indicated that such care should be individualized, planned, and performed according to established procedures, with documentation required every shift. The incident demonstrated a failure to provide adequate supervision and to follow proper repositioning protocols, as the resident was handled in a manner inconsistent with facility policy and best practices for dependent residents.
Inadequate Infection Control Leads to Candida Auris Outbreak
Penalty
Summary
The facility failed to maintain an effective infection control program, resulting in the spread of Candida auris among residents. Observations revealed that staff did not consistently use personal protective equipment (PPE) or perform hand hygiene when entering and exiting rooms of residents on contact precautions. Specifically, CNA B and LVN M were observed not adhering to proper infection control protocols, such as failing to wash or sanitize hands and not changing PPE between resident interactions. This negligence contributed to the transmission of Candida auris within the facility. Interviews with staff, including the Infection Preventionist (IP B) and the Local Health Department Epidemiologist, highlighted significant gaps in the facility's infection control practices. IP B, who was newly hired, was unaware of the number of residents affected by Candida auris and lacked a clear plan to mitigate the infection's spread. The facility's previous Infection Preventionist and Director of Nursing (DON) had been working with the health department, but there was no evidence of a surveillance plan being implemented to track and monitor infections effectively. The facility's administration also demonstrated a lack of awareness and oversight regarding the infection control program. The Administrator could not articulate a structured system to mitigate the risk of Candida auris transmission and was unaware of the number of residents affected. The facility's failure to implement and monitor transmission-based precautions, as well as the lack of staff training on Candida auris, contributed to the ongoing outbreak and placed residents at risk of exposure to the infection.
Removal Plan
- Candida auris Education: The Regional Nurse Consultant initiated education provided to all staff on Candida auris (including background/definition, PPE & isolation protocols (including co-horting), disinfectant protocols, equipment/clothes/linen handling, meal service, and methods to prevent the spread of Candida auris). Staff will be educated prior to initiating their next shift. Staff will show competency and understanding of education through testing. Education on Candida auris, including testing will occur in Facility Orientation.
- Environmental Cleaning Education: The Regional Nurse Consultant initiated education provided to housekeeping staff on cleaning schedules for residents affected by Candida auris and the requirement to clean/disinfect twice a day and using EPA-approved disinfectants effective against Candida auris per the county health department recommendations. Housekeeping staff will be educated prior to initiating their next shift. The Administrator will ensure compliance.
- Infection Control Education: The Regional Nurse Consultant initiated education with all staff on Handwashing and Equipment Disinfection between resident rooms. Staff will be educated prior to initiating their next shift.
- 1:1 Education: The Regional Nurse Consultant provided 1:1 education with the Infection Preventionist, Weekend RN Supervisor, and Administrator on Candida auris, Infection Prevention Program Policy to include surveillance.
- Medical Director Notification: The Administrator notified the Medical Director of the IJ template and will be updated on the POR as indicated.
- Surveillance: The Regional Nurse Consultant audited 100% of resident's charts to identify residents with a presence of Candida auris and whether the infection was facility or community acquired. Outcome: (12) facility acquired & (16) Community acquired. Active surveillance listing will be maintained by the Facility Infection Preventionist to include Infection Type and acquired status (Facility vs Community).
- Sustainability: The Administrator is responsible for reviewing all compliance reports (including health department recommendations) and taking immediate corrective action where needed. The Infection Preventionist or Weekend RN Supervisor will conduct Daily audits for PPE compliance and environmental cleaning logs will continue for 30 days and then as needed. The Infection Preventionist will collaborate with the health department as directed and will ensure recommendations are carried out timely.
- Policy / Recommendation Review: The Administrator reviewed the Infection Control Program Policy and Procedure and the Candida auris policy and procedure and no updates were required. The Regional Nurse Consultant, IP, and Administrator reviewed the current Health Department recommendations and initiated Candida auris training and increased environmental cleaning.
Deficient Call Light System Leads to Delayed Care
Penalty
Summary
The facility failed to maintain a functioning call light system for five months, affecting all four halls. This deficiency left residents without a reliable means to call for staff assistance, particularly in emergencies. The call light system was damaged by inclement weather, and despite the facility's attempts to replace it, the system remained non-functional. Residents were provided with alternative devices like cowbells and buzzers, but these were not always effective or accessible, leading to delays in care. One resident, who was quadriplegic and required continuous mechanical ventilation, experienced a significant delay in receiving care due to the lack of a functioning call system. The resident's family attempted to contact the facility 45 times without success, ultimately calling 911 when the resident showed signs of respiratory distress. Upon EMS arrival, the resident was found to be febrile, tachycardic, and in need of suctioning, highlighting the critical nature of the deficiency. Other residents also faced challenges due to the broken call system. One resident had a buzzer provided by their family, but its sound was not always audible to staff. Another resident was unaware of the availability of a bell for assistance, and a third resident had no device to call for help. These observations underscore the facility's failure to ensure that all residents had adequate means to request assistance, posing a risk of delayed medical care and assistance with daily activities.
Failure to Address Resident's Change in Condition
Penalty
Summary
The facility failed to provide appropriate treatment and care to a resident who experienced a significant change in condition during the night shift. The resident, who had a complex medical history including quadriplegia, tracheostomy, and chronic respiratory failure, showed signs of distress such as shortness of breath, fever, tachycardia, and diaphoresis. Despite these symptoms, the night shift staff did not recognize or provide necessary clinical interventions, resulting in a delay in urgent medical treatment. The resident's family attempted to contact the facility approximately 45 times between 1:53 a.m. and 3:47 a.m. to report the resident's condition, but their calls went unanswered. The resident, who was able to communicate using an eye tracker system, indicated to family members that he was experiencing difficulty breathing and needed assistance. Eventually, the family called 911, and emergency medical services arrived to find the resident in moderate distress with a high fever and occluded tracheostomy tube. Interviews with facility staff revealed that the resident's condition was not adequately monitored, and vital signs were not consistently checked. The staff did not respond to the family's calls, and the resident's symptoms were not addressed until EMS arrived. The facility's Director of Nursing acknowledged the communication issues and the need for staff to anticipate the resident's needs due to his inability to use call bells or buzzers.
Failure to Develop Comprehensive Baseline Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a newly admitted resident, identified as CR #1, which included necessary instructions to provide effective and person-centered care. This deficiency was observed in the case of CR #1, who was admitted with significant medical conditions including quadriplegia, a tracheostomy, and chronic respiratory failure requiring continuous mechanical ventilation. Despite these complex needs, the baseline care plan did not address critical areas such as communication methods, tracheostomy/ventilator care, and management of nighttime anxiety. CR #1's medical history included a gunshot wound leading to severe injuries and subsequent quadriplegia, necessitating a tracheostomy and mechanical ventilation. Upon admission, CR #1 was able to communicate using an eye tracker system on his tablet, which was not documented in the baseline care plan. Additionally, the care plan failed to include specific instructions for tracheostomy care and suctioning, despite physician orders indicating the need for regular suctioning every two hours or as needed. The resident's tendency to experience anxiety during the night was also not addressed, even though this information was communicated to the facility by the resident's representative. Interviews with facility staff, including the DON, ADON, and other nursing staff, revealed a lack of comprehensive assessment and documentation in the baseline care plan. The staff acknowledged that the baseline care plan should have included all identified needs upon admission, but these were not adequately captured or updated. The facility's policy required a baseline care plan to be developed within 48 hours of admission, yet CR #1's plan was incomplete, leaving critical care areas unaddressed during his stay.
Deficiency in Supply Management and Availability
Penalty
Summary
The facility failed to ensure that staff had gloves readily available to provide care for residents, which could lead to delays in care and increased risk of infections and hygiene concerns. Interviews with staff and residents revealed that gloves were not easily accessible, and staff often had to wait for central supply to deliver them. This issue was exacerbated by a recent storm, which delayed supply deliveries. Despite the Central Supply Supervisor's claim that the facility never ran out of gloves, multiple anonymous interviews indicated that staff frequently struggled to find gloves and had to rely on central supply or other departments to obtain them. The Central Supply Supervisor stated that she ordered supplies regularly and had no issues with contracts, but acknowledged a delay in receiving supplies due to the storm. However, interviews with company representatives revealed that the facility's supply orders were on hold due to unpaid invoices, which contradicted the Administrator's assertion that the facility had not run out of supplies. The Administrator mentioned using multiple supply companies and local stores to ensure supplies were available, but also noted that not everyone had access to supplies due to theft concerns. Residents reported that staff sometimes had to hunt for supplies, and there were instances where residents were not changed promptly due to a lack of appropriate supplies. The Director of Nursing, who had only been at the facility for a short time, was unaware of why bills were not being paid. The facility's policy on ordering supplies indicated that a purchasing agent was responsible for processing orders, but it appears there was a disconnect between ordering, payment, and supply availability, leading to the deficiency.
Failure to Provide Timely Emergency Medical Treatment
Penalty
Summary
The facility failed to provide timely emergency medical treatment to two residents, leading to significant deficiencies in their care. The first resident, a male with end-stage renal disease, missed several days of dialysis due to a problematic central venous catheter. Despite the dialysis nurse's concerns about fluid overload and a doctor's order for hospital evaluation, the resident was not promptly transferred to the hospital. Instead, non-emergency medical transportation was scheduled, resulting in a delay. The resident was later found unresponsive and pronounced deceased after unsuccessful resuscitation efforts. The second resident, also with end-stage renal disease, required a blood transfusion due to low hemoglobin levels. Although the dialysis nurse received a doctor's order for hospital transfer, the resident was transported via non-emergency services, which took several hours to arrive. During this time, the resident remained at the facility without receiving the necessary emergency treatment. The care plan for this resident did not include specific goals or interventions related to dialysis, indicating a lack of comprehensive planning for his condition. Interviews with facility staff revealed communication issues and a lack of urgency in responding to the residents' medical needs. The Director of Nursing and other staff members did not recognize the situations as emergencies, relying on non-emergency transportation despite the critical nature of the residents' conditions. The facility's policies on charting, documentation, and changes in residents' conditions were not adequately followed, contributing to the deficiencies in care.
Failure to Provide Timely Dialysis Care Leads to Resident's Death
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident who required such services, leading to a critical situation. The resident, a male with end-stage renal disease and other significant health issues, did not receive hemodialysis treatments as ordered by his physician. This resulted in symptoms of fluid overload, requiring emergency medical care. The resident's dialysis access port malfunctioned, and he did not receive dialysis for four days, which contributed to his deteriorating condition. The report details multiple instances where the resident's dialysis treatment was either missed or incomplete due to issues with the dialysis catheter. Despite the resident's critical need for dialysis, there was a lack of communication and coordination between the facility and the dialysis center. The dialysis staff was not informed of the resident's return to the facility after a hospital visit, leading to further delays in treatment. Additionally, when the resident's catheter malfunctioned, there was a failure to promptly address the issue, resulting in the resident missing several dialysis sessions. The situation escalated when the resident was found unresponsive, and despite efforts to resuscitate him, he was pronounced deceased. Interviews with staff revealed a lack of urgency in addressing the resident's condition, with non-emergency transport being scheduled instead of immediate medical intervention. The facility's policies and procedures for handling such critical situations were not effectively implemented, contributing to the resident's untimely death.
Failure to Report and Investigate Alleged Violations
Penalty
Summary
The facility failed to provide evidence that all alleged violations were thoroughly investigated and reported to the appropriate authorities within the required timeframe. Specifically, the facility did not complete a Provider Investigation Report (PIR) for three separate intakes involving allegations of infection control, physical environment issues, and abuse. These intakes involved six residents, and the facility did not submit the necessary reports through the Texas Unified License Information Portal (TULIP) as required by state law. Interviews with the facility's Administrator revealed a misunderstanding of the reporting requirements, as she believed that sending an email to TULIP was sufficient instead of completing the 3613-A PIR form. The Regional Nurse confirmed that the Administrator was trained by the corporate team and that the facility was supposed to notify the corporate team of self-reports before submission. However, the Regional Nurse was unaware of any self-reports other than a recent abuse allegation. The facility's policy required a follow-up investigation report within five business days, but this was not adhered to, leading to a failure in reporting and investigating alleged violations.
Failure to Provide Appropriate Tracheotomy Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident requiring tracheotomy care, specifically in maintaining sterile technique and notifying the resident's physician when the resident changed her inner cannula. The resident, who was cognitively intact and had multiple complex medical conditions including acute and chronic respiratory failure, COPD, and a tracheostomy, independently changed her inner cannula without sterile technique, which was not documented or reported to the physician as per facility policy. The resident's care plan did not include interventions related to her ability or desire to change her inner cannula independently, and there was a lack of documentation and communication regarding her respiratory care needs. The resident reported that she had been changing her inner cannula two to three times a week without the knowledge of the respiratory therapy department or consistent assistance from nursing staff. The facility's respiratory care policy required sterile technique and documentation of the procedure, which was not followed in this case. Interviews with staff revealed a lack of clarity and training regarding the responsibilities of nurses in providing tracheostomy care. The LVN involved did not perform an assessment or notify the appropriate personnel after learning the resident had changed her inner cannula. The DON and other staff acknowledged gaps in training and communication, which contributed to the deficiency in care provided to the resident.
Failure to Maintain Safe Operating Condition of Call Light System
Penalty
Summary
The facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, specifically the call light system in shower room [ROOM NUMBER]. Observations revealed that call light #2 in shower stall #2 had exposed wires and no emergency call light cord, which could place residents at risk of not receiving emergency care in a timely manner. The Maintenance Director, who had only been in his role for two days, was unaware of the issue until it was brought to his attention during the survey. He stated that the wires were not live and posed no danger, but this was not verified by any testing or documentation. Interviews with various staff members, including Central Supply staff, CNAs, and the Utility Tech, indicated that none of them were aware of the exposed wires or missing call light cord in shower stall #2. The staff members stated that they would have reported such issues to the maintenance department if they had noticed them. However, no repair requests for the call light system in shower room [ROOM NUMBER] were found in the maintenance request logs for the months of January through April 2024. Resident #1, who regularly used the shower room, confirmed that she had noticed the exposed wires in shower stall #2 for several months and avoided using that stall out of fear of electrocution. The facility's Maintenance Service Policy requires the maintenance department to keep the building and equipment in safe and operable condition at all times, but this policy was not followed in this instance. The lack of awareness and reporting among staff, combined with the failure to document and address the issue, led to the deficiency in maintaining a safe environment for residents.
Failure to Maintain Working Call System in Shower Room
Penalty
Summary
The facility failed to ensure that a working call system was available in each resident's bathroom and bathing area, specifically in shower stall #2 in shower room [ROOM NUMBER]. Observations revealed that the call bell system in this shower stall had an open electrical socket with no call bell cord and exposed wiring. Multiple staff members, including the Maintenance Director, CNAs, and the Utility Tech, were unaware of the issue, indicating a lack of proper maintenance and oversight. The Maintenance Director eventually acknowledged the problem and took steps to cover the exposed wires, but this was only after the surveyor's observations and interviews highlighted the deficiency. Resident #1, a cognitively intact individual with a history of falls and dependence on a ventilator, had noticed the exposed wires in shower stall #2 for several months. Despite this, there were no maintenance requests logged for the call light system in the shower room from January to April 2024. This indicates a significant lapse in the facility's maintenance and reporting procedures, as the issue had been present for an extended period without being addressed. Interviews with various staff members, including CNAs and the HRM, revealed that none of them had noticed the missing call bell plate or exposed wires during their shifts. This lack of awareness and reporting further underscores the facility's failure to maintain a safe environment for its residents. The facility's Maintenance Service Policy, which mandates maintaining the building and equipment in a safe and operable manner, was not adhered to, leading to this deficiency.
Deficient Call System in 200-Hall Restrooms
Penalty
Summary
The facility failed to provide a functioning call system in the restrooms of the 200-Hall, which is essential for residents to call for staff assistance. Observations revealed that when the call light cords were pulled in the restrooms, the exterior lights did not activate, and the sound of the emergency bells was faint. Staff members, including a Medical Assistant (MA), Licensed Vocational Nurse (LVN), and Certified Nursing Assistants (CNAs), confirmed that the bells were not loud enough to ensure they could hear them, especially if they were not specifically listening for them. Interviews with staff members indicated that the call lights in the restrooms had been non-functional for an extended period, with some staff unsure of the exact duration. The facility had resorted to using bells attached to the call light cords, but these were not effective in alerting staff to emergencies. The Director of Nursing (DON) and the Administrator acknowledged the issue, with the Administrator noting that the call light system had been problematic since before January 2023. A review of the facility's records showed a lack of consistent inspection logs for the 200-Hall call lights, with several months missing. An estimate dated March 2024 indicated that the current call light system was beyond repair and required replacement. This deficiency in the call system could potentially prevent residents from receiving timely assistance, as staff might not be aware of emergencies occurring in the restrooms.
Failure to Notify Physician and Family of Change in Condition
Penalty
Summary
The facility failed to consult with the resident's physician and notify the resident's representative for a resident who experienced a change in condition. The resident, who had a history of type 2 diabetes, kidney failure, cerebral infarction, malnutrition, hemiplegia, high blood pressure, sepsis, and heart disease, began vomiting a brown substance repeatedly. Despite this significant change in condition, the facility staff did not immediately notify the physician. Additionally, the resident's insulin NPH was discontinued without proper notification to the physician, even though the resident was experiencing high glucose readings for six days. The resident's blood sugar levels were consistently high, with readings reaching as high as 598 mg/dL. The facility's care plan required that any abnormal findings be reported to the physician and family members, but this was not done. Interviews with staff revealed confusion and lack of documentation regarding the resident's condition and the actions taken. The resident was eventually sent to the hospital, where she died. Interviews with various staff members, including CNAs, LVNs, and the DON, highlighted a lack of communication and documentation regarding the resident's condition. The facility's policy required notification of the physician and resident's representative in the event of a significant change in condition, but this was not adhered to. The failure to notify the physician and the discontinuation of insulin without proper oversight contributed to the resident's decline and eventual death.
Failure to Recognize and Respond to Resident's Change in Condition
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, leading to a significant deficiency in quality of care. The resident, who had a history of type 2 diabetes, kidney failure, cerebral infarction, malnutrition, hemiplegia, high blood pressure, sepsis, and heart disease, experienced a change in condition that was not adequately recognized or addressed by the facility staff. The resident began vomiting and had extremely high blood glucose levels for several days, which were not properly monitored or managed according to the care plan and physician's orders. The facility's staff did not follow the prescribed protocol for monitoring and responding to the resident's high blood glucose levels. Despite the resident's blood sugar readings consistently exceeding 300 mg/dL, and at times reaching above 600 mg/dL, there was a lack of timely intervention and communication with the physician. The insulin NPH, which was part of the resident's treatment plan, was erroneously discontinued, and the facility failed to administer insulin as required by the sliding scale orders. Additionally, the facility delayed in sending the resident to the hospital, opting to call a non-emergency line despite the resident's critical condition, which included non-responsiveness, a blood sugar level of 598 mg/dL, and an oxygen saturation of 88%. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's condition. Several staff members, including CNAs and nurses, noted the resident's vomiting and high blood sugar levels but did not take appropriate action or document the events accurately. The facility's policies on blood sugar checks, oxygen saturation, and change in condition were not adhered to, contributing to the resident's deterioration and eventual hospitalization, where the resident later died.
Failure to Administer Insulin Leads to Resident's Hospitalization and Death
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident with type 2 diabetes, kidney failure, cerebral infarction, malnutrition, hemiplegia, high blood pressure, sepsis, and heart disease. The resident was initially admitted to the facility with orders for insulin NPH and Lispro to manage her diabetes. However, a nurse erroneously discontinued both insulin medications following a verbal order to discontinue only the insulin Lispro due to low blood sugar levels. This error left the resident without necessary insulin coverage, leading to high blood sugar levels over several days. Despite the resident's blood sugar readings being significantly elevated, reaching levels as high as 491 mg/dL, the facility staff failed to notify the physician or take appropriate action to address the hyperglycemia. Interviews with various nursing staff revealed a lack of communication and documentation regarding the resident's insulin orders and blood sugar management. The Lead Nurse Practitioner confirmed that the discontinuation of insulin NPH was not authorized and emphasized the importance of maintaining NPH for basal coverage. The Director of Nursing and other staff members acknowledged that the nurses were responsible for ensuring the accuracy of medication orders and for contacting the physician if blood sugar levels exceeded 300 mg/dL. However, the facility's failure to adhere to these protocols resulted in the resident being sent to the hospital, where she subsequently died. The facility's policy on administering medications was not followed, contributing to the resident's deteriorating condition and eventual death.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 339 citations issued within 25 miles in the last 12 months — including the 32 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Katy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Park Of Katy Nursing And Rehabilitation | 2.3 mi | ★★★★★ | 0 | 0 |
| Ignite Medical Resort Katy, Llc | 3.1 mi | ★★★★★ | 4 | 0 |
| Falcon Point Post Acute | 3.3 mi | ★★★★★ | 9 | 0 |
| Sterling Oaks Rehabilitation | 3.4 mi | ★★★★★ | 13 | 0 |
| Mason Creek Transitional Care Of Katy | 5.4 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.