Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Sweeny during CMS and state inspections, most recent first.
Improper Incontinent Care and Hand Hygiene: A resident with bowel and bladder incontinence, severe cognitive impairment, and multiple medical diagnoses received incontinent care from a CNA who kept contaminated gloves on throughout care, failed to perform hand hygiene, did not fully clean the groin area, and used the same wipe and gloves while handling the resident’s brief, bed area, and food tray setup.
Infection Control Failure During Peri Care: A CNA provided incontinent care to a resident with severe cognitive impairment, frequent bowel and bladder incontinence, and diagnoses including cellulitis and DM. During care, the CNA did not clean both groins or retract the foreskin, reused the same wipe, handled a trash can and the resident’s bedside table with contaminated gloves, and did not change gloves or perform hand hygiene between tasks. The CNA and DON both acknowledged that gloves should have been changed and hand hygiene performed to prevent cross-contamination.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Multiple residents with cognitive and behavioral health needs experienced significant incidents, including ingestion of inedible items and inappropriate sexual contact, but their care plans were not updated with individualized, measurable interventions or objectives following these events. Staff and documentation confirmed that care plans did not reflect recent incidents or provide updated strategies, despite facility policy requiring timely revisions.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and not providing adequate supervision to prevent accidents. The report highlights insufficient safety measures and lack of proper oversight, but does not specify individual residents or staff involved.
Three residents with complex medical conditions were not provided with the required Notice of Medicare Non-Coverage or Beneficiary Notice CMS form 10055 when their coverage status changed or services were no longer covered. Facility staff confirmed that these notifications were not issued as required by policy, and documentation was missing from the residents' records.
Surveyors found that kitchen staff failed to label and date opened or prepared food items, including gravy, milk, and gelatin, and did not discard expired cooked food and juice thickener. Dietary staff and the administrator confirmed that these actions did not meet facility policy or professional standards for food safety.
A resident with multiple medical conditions was discharged to a private home with home health services, but the facility failed to notify the State LTC Ombudsman in writing or provide the required discharge notice in an understandable manner. Staff interviews and record review confirmed that the Ombudsman was not informed and proper documentation was not completed, contrary to facility policy.
Two residents with severe cognitive impairments experienced incidents that were not properly investigated or reported by the facility. One resident was found with injuries from an unwitnessed fall, and another alleged abuse during a delusional episode. The facility staff failed to follow policies for investigation and reporting, placing residents at risk.
A facility failed to report an unwitnessed fall and an alleged abuse incident to the SSA within the required timeframe. A resident with severe cognitive impairment was found with injuries after a fall, but the incident was not reported. Another resident alleged abuse, but staff did not report it, attributing the claim to the resident's mental illness. Interviews revealed confusion over reporting guidelines.
The facility failed to investigate and report allegations of abuse for two residents with severe cognitive impairments. One resident was found with injuries from an unwitnessed fall, and another alleged abuse by an unidentified person. The facility did not conduct thorough investigations or report the incidents to the state agency, assuming the latter was a delusion. Staff interviews revealed a lack of proper documentation and investigation procedures.
The facility failed to update the comprehensive care plans for three residents, missing critical updates such as the discontinuation of a Foley catheter, significant weight loss, diet, ADLs, use of antipsychotic medication, and the presence of a newly acquired pressure wound.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Expired food items were found in the refrigerator, and an open bag of cornflakes was not labeled. The Dietary Manager was observed preparing food without wearing a hairnet or beard guard, contrary to policy. The Administrator confirmed awareness of these issues and the associated risks.
The facility failed to develop a baseline care plan within 48 hours for a newly admitted resident with a history of cerebral infarction and muscle wasting, completing it 72 hours after admission instead. Interviews revealed inconsistencies among staff regarding the timeline for completing baseline care plans.
A resident with a G-tube did not receive medications properly dissolved in water before administration, as observed with an LVN who was unaware of the correct procedure. The resident, with a history of hemiplegia, bacteremia, and malignant neoplasm of the brain, was at risk due to this improper practice.
A facility failed to maintain an infection prevention and control program when an LVN did not perform hand hygiene between glove changes during wound care for a resident with chronic ulcers, potentially exposing the resident to infections.
Improper Incontinent Care and Hand Hygiene
Penalty
Summary
The facility failed to ensure appropriate incontinent care and hand hygiene for a resident who was incontinent of bowel and bladder and required maximal assistance with toileting hygiene. The resident was a 73-year-old male with metabolic encephalopathy, cellulitis, dementia, muscle wasting and atrophy of the lower leg, and diabetes mellitus. His MDS showed a BIMS of 05, indicating severely impaired cognition. His care plan directed staff to provide assist with bathing/hygiene and toileting, monitor for signs and symptoms of UTI, and perform routine rounding including incontinence care and brief changing. During observation, a CNA provided incontinent care but did not remove contaminated gloves or perform hand hygiene while completing the task. The CNA wiped the resident's right groin three times but did not clean the left groin or pull back the foreskin of the penis to clean. The CNA stopped care to retrieve a trash can, picked it up with dirty gloves, and placed it beside the bed without changing gloves or performing hand hygiene. The CNA then placed a clean brief on the resident while visible yellow residue remained on the right buttock and was transferred to the clean brief, used the same wipe between the buttocks, and continued touching the resident's bedside table to set up the food tray with the same gloves used for incontinent care.
Infection Control Failure During Peri Care
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to prevent the development and transmission of disease and infection for one resident reviewed for infection control. The resident was a 73-year-old male admitted with metabolic encephalopathy, cellulitis, dementia, muscle wasting and atrophy of the lower leg, and diabetes mellitus. His MDS showed a BIMS of 05, indicating severely impaired cognition, and that he required maximal assistance with toileting hygiene and was frequently incontinent of bladder and bowel. During an observation, a CNA provided incontinent care and opened and pulled down the resident’s adult brief. The CNA wiped three times on the resident’s right groin but did not clean the left groin or retract the foreskin to clean the penis. The CNA then stopped care to retrieve a trash can, picked it up with dirty gloves still on, and placed it beside the resident’s bed without changing gloves or performing hand hygiene. The CNA then placed a clean adult brief on the resident, and visible yellow residue on the resident’s right buttock was transferred to the clean brief. The CNA also wiped between the resident’s buttocks using the same wipe and finished applying the brief without changing gloves or performing hand hygiene. The CNA then touched the resident’s bedside table to set up the food tray while still wearing the same gloves used for incontinent care. In interview, the CNA stated he should have changed gloves after peri care and removed contaminated gloves and performed hand hygiene after touching the resident’s environment. The DON stated the facility follows CDC recommendations regarding hand hygiene and that touching multiple surfaces after incontinent care could have caused cross-contamination. The facility’s Perineal Care policy required cleaning the penis from the tip down to the base, retracting the foreskin if applicable, removing soiled gloves and performing hand hygiene before applying a clean brief, and washing hands after removing gloves.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Update Care Plans After Behavioral and Safety Incidents
Penalty
Summary
The facility failed to develop and implement complete, individualized care plans with measurable objectives and timetables for multiple residents following significant behavioral incidents. One resident with a history of dementia, anxiety, altered mental status, and intellectual disabilities ingested plastic wrap from a dessert cup during a meal. Despite a documented history of ingesting inedible items, the resident's care plan was not updated to address the most recent incident, nor did it include new interventions or services to mitigate the risk of recurrence. Staff interviews confirmed that the care plan did not reflect the incident or provide updated strategies for prevention. Two other residents, both with cognitive impairments and psychiatric diagnoses, were involved in incidents of inappropriate sexual contact, including being found naked together in bed and engaging in physical contact. Their care plans did not include goals or interventions to address these behaviors, despite repeated incidents and documentation in progress notes. Staff interviews revealed that the care plans were not updated to reflect these behaviors, and there was no documentation of interventions to prevent further inappropriate contact or to address the residents' inability to make consensual decisions. The facility's policy required care plans to be reviewed and revised quarterly, upon status changes, or as necessary, with updates to interventions as needed. However, the care plans for these residents were not revised in a timely manner following the incidents, resulting in a failure to provide appropriate, individualized care and services as required. The deficiency was identified as Immediate Jeopardy due to the lack of updated care plans with measurable objectives and timeframes after significant behavioral events.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential incidents. Specific actions or omissions by staff or management that led to this deficiency are not detailed in the report, nor are any particular residents or their medical histories mentioned.
Failure to Provide Required Medicare/Medicaid Coverage Notices
Penalty
Summary
The facility failed to provide required notices to residents regarding changes in Medicare/Medicaid coverage and potential financial liability for services not covered. Specifically, three residents were not given the Notice of Medicare Non-Coverage (NOMNC) or the Beneficiary Notice CMS form 10055 when their coverage status changed or services were no longer covered. Record reviews confirmed that these forms were not present in the residents' files, and interviews with facility staff, including the social worker and administrator, confirmed that the notices were not issued as required by policy. The residents involved had complex medical histories, including conditions such as joint replacement aftercare, traumatic brain injury, dementia, contractures, schizoaffective disorder, legal blindness, anemia in chronic kidney disease, esophageal obstruction, pressure ulcers, and Down syndrome. One resident was discharged to a private home with home health services, while two others remained in the facility. The facility's own policy required that the NOMNC be delivered no later than two calendar days before the end of skilled services, but this was not followed for the residents reviewed.
Failure to Properly Label, Date, and Discard Food Items in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding the storage, labeling, and dating of food items. Specifically, chicken gravy and two glasses of milk stored in the walk-in refrigerator were not labeled or dated, and cherry gelatin in the dry storage area was also found without a label or date. Additionally, cooked beef chili in the refrigerator was not labeled with an expiration date, and a bottle of apple juice thickener remained in dry storage past its best used by date. These issues were identified during a kitchen observation and confirmed through interviews with dietary staff and the administrator, who acknowledged that all opened or prepared foods should be labeled and dated according to facility policy and professional standards. Record review of the facility's Nutrition Services policy and the FDA Food Code confirmed that food items must be labeled with the date they are opened or prepared and discarded by the appropriate date to minimize contamination and bacterial growth. The dietary manager and tray aide both stated that it was their responsibility to ensure proper labeling and dating of food items, and recognized that failure to do so could result in expired or unsafe food being served. The administrator also acknowledged the risks associated with improper food storage practices.
Failure to Notify Ombudsman and Document Resident Discharge Process
Penalty
Summary
The facility failed to provide and document adequate preparation and orientation for a resident's representative to ensure a safe and orderly transfer or discharge. Specifically, the facility did not notify the resident's representative, which in this case was the Office of the State Long-Term Care Ombudsman, of the transfer or discharge in writing, nor did they provide the reasons for the move in a language and manner that could be understood. Additionally, a copy of the notice of transfer or discharge was not sent to the Ombudsman representative as required by facility policy. Interviews with facility staff revealed that the responsibility for beneficiary notices was assigned to the business office manager and social worker, but the Ombudsman was not notified. The social worker also stated that she only worked with skilled residents and not long-term residents. The resident involved had a history of joint replacement surgery, diffuse traumatic brain injury, unspecified convulsions, and hallucinations. The resident was discharged to a private home with home health services after a 39-day stay. Documentation showed that the resident was picked up by their representative and referred to home health for continued physical therapy, with follow-up appointments scheduled with their primary care provider. However, the required notifications to the Ombudsman and proper documentation of the discharge process were not completed, as confirmed by record review and staff interviews.
Failure to Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to implement its policies and procedures to prevent abuse and neglect for two residents. The first resident, who had severe cognitive impairment and a history of falls, was found on the floor with a skin tear and hematoma. The incident was unwitnessed, and the resident could not explain how it occurred. Despite the facility's policy requiring thorough investigation and reporting of such incidents, there was no evidence of a comprehensive investigation or report to the state authorities. The second resident, also with severe cognitive impairment and a history of delusions, alleged an incident of abuse while speaking with a family member. The family member reported the allegation to the facility staff, but the staff did not conduct a thorough investigation or report the incident to the state. The staff assumed the resident's claim was a result of delusional behavior and did not follow the facility's policy for investigating and reporting allegations of abuse. Interviews with facility staff revealed a lack of proper documentation and investigation procedures. The Administrator and DON were aware of the incidents but did not ensure that the required investigations and reports were completed. The facility's failure to investigate and report these incidents as per their policies and state regulations placed residents at risk for further abuse and neglect.
Failure to Report Unwitnessed Fall and Alleged Abuse
Penalty
Summary
The facility failed to report an unwitnessed fall involving a resident who was found on the floor with injuries, including a skin tear and hematoma, to the State Survey Agency (SSA) within the required timeframe. The resident, who had severe cognitive impairment and a history of repeated falls, was unable to provide details on how the fall occurred. Despite the presence of injuries, the incident was not reported to the SSA, as it was deemed an oversight by the facility's administrator. Additionally, the facility did not report an allegation of abuse made by another resident, who claimed to have been beaten and dragged by an unidentified person. The resident, who also had severe cognitive impairment and a history of delusional episodes, showed no physical signs of abuse upon assessment. The social worker and the Director of Nursing (DON) did not report the allegation to the SSA, as they believed it was a result of the resident's mental illness and not a credible claim. Interviews with facility staff revealed a lack of clarity and adherence to reporting guidelines for incidents involving potential abuse or neglect. The administrator acknowledged that any allegation, regardless of the resident's mental state, should have been reported to the SSA for investigation. The failure to report these incidents could potentially place residents at risk of unaddressed abuse or neglect.
Failure to Investigate and Report Allegations of Abuse
Penalty
Summary
The facility failed to thoroughly investigate and prevent further potential abuse, neglect, exploitation, or mistreatment for two residents. One resident was found on the floor with a skin tear and hematoma, but the facility did not conduct a thorough investigation into the incident. The resident, who had severe cognitive impairment and a history of falls, was unable to provide details on how the incident occurred. Despite the injuries, there was no evidence of a comprehensive investigation or reporting to the state agency. Another resident, also with severe cognitive impairment and a history of delusional episodes, alleged abuse by an unidentified person. The facility did not report this allegation to the state agency, nor did they conduct a thorough investigation. The staff assumed the incident was a result of the resident's delusions and did not take further action. The resident's family member reported the allegation to the facility, but the staff did not follow the proper procedures for investigation and reporting. Interviews with facility staff revealed a lack of proper documentation and investigation procedures. The Administrator and DON did not ensure that allegations of abuse were reported and investigated as required by facility policy. The facility lacked a policy for Provider Investigation Reports, and there were no soft files maintained for the incidents involving the two residents. This failure to investigate and report allegations of abuse could have placed residents at risk for further harm.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for three residents. Resident #52's care plan was not updated to reflect the discontinuation of a Foley catheter and the resident's current status of bladder incontinence without the catheter. Additionally, the care plan did not address the resident's significant weight loss and the physician-ordered weekly weights. Resident #220's care plan lacked updates to include the resident's diet, ADLs, and the use of an antipsychotic medication, despite these needs being indicated on the MDS assessment. The care plan only addressed full code status, new to the nursing facility, cognitive impairment, and behavior problems, missing critical aspects of the resident's care needs. Resident #15's care plan did not include the presence of a newly acquired pressure wound, despite the resident's severe cognitive impairment and other significant health issues. The MDS Coordinator and the Administrator acknowledged the responsibility of revising care plans during weekly Quality of Care meetings and with any change in the resident's condition. However, the failure to update these care plans as required could lead to inadequate care and safety risks for the residents.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation of the kitchen, several food items in the refrigerator were found to have expired use-by dates, including nine cans of mild fire-roasted diced green chiles and a container of fruit punch. Additionally, an open bag of cornflakes in the storage room was not labeled with an opening date. The Dietary Manager, who had been at the facility for three weeks, acknowledged that these items should be discarded due to their expired dates and lack of labeling. Furthermore, the Dietary Manager was observed preparing food without wearing a hairnet or beard guard, which he admitted was against policy and posed a risk of cross-contamination and foodborne illness to residents. The Administrator confirmed awareness of the expired food items and the importance of proper labeling and dating to prevent food poisoning. The facility's policies and procedures for food storage and dress code were reviewed, revealing that all food containers must be labeled and dated, and refrigerated leftovers should be used within 72 hours. The dress code policy required appropriate hair restraints, such as hairnets and beard guards, to be worn during food production activities. Despite these policies, the Dietary Manager had not been adequately trained on these requirements, leading to non-compliance. The Administrator acknowledged the risks associated with these deficiencies, including potential food contamination and infection control issues, and confirmed that a labeling and dating in-service had been conducted by the Registered Dietitian.
Failure to Develop Timely Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by policy. The resident, a male with a history of cerebral infarction, muscle wasting, and atrophy, was admitted to the facility and required substantial assistance with various activities of daily living. However, the baseline care plan for this resident was completed 72 hours after admission, not within the mandated 48-hour timeframe. Interviews with facility staff, including the MDS Coordinator, DON, and Administrator, revealed inconsistencies and misunderstandings regarding the timeline for completing baseline care plans. The MDS Coordinator and DON both indicated that baseline care plans were typically completed within 72 hours, with exceptions made for weekends. The Administrator, however, stated that baseline care plans were due upon admission. This discrepancy in understanding and execution led to the delay in developing the baseline care plan for the resident, potentially placing newly admitted residents at risk of not receiving timely and appropriate care.
Improper G-Tube Medication Administration
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services for Resident #170, who required medication administration through a G-tube. During an observation, LVN B was seen crushing the resident's medications and administering them directly into the G-tube without dissolving them in water first. This practice was contrary to the facility's policy, which mandates that crushed medications be mixed with 10-15 ml of water before administration. LVN B admitted to not being aware of the correct procedure and acknowledged the risks associated with not dissolving the medications, such as incomplete medication delivery and potential clogging of the G-tube. Resident #170, a male with a history of hemiplegia, bacteremia, and malignant neoplasm of the brain, was at risk due to this improper medication administration. The Director of Nursing (DON) confirmed that the correct procedure involves dissolving crushed medications in water and flushing the G-tube before, between, and after medication administration. The facility's policy, revised in June 2019, also supports this procedure to ensure safe and effective medication delivery through G-tubes.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, as evidenced by the actions of LVN A during wound care for a resident. LVN A did not perform hand hygiene between glove changes while treating the resident's sacral wound and other areas, despite the facility's policy requiring hand hygiene to prevent infections. This lapse in protocol was observed during a wound care session, where LVN A changed gloves multiple times without sanitizing her hands, potentially exposing the resident to communicable diseases and infections. The resident involved was a male with a history of non-pressure chronic ulcers on his left heel and mid-left foot, admitted to the facility with multiple diagnoses. His care plan indicated he was at risk for further skin breakdown and infection, with specific interventions outlined for wound care. During the observed wound care session, LVN A failed to follow proper infection control procedures, which included not sanitizing hands between glove changes while treating the resident's wounds. Interviews with LVN A, the DON, and the Administrator revealed that the facility's policy required hand hygiene between glove changes to prevent infections. LVN A admitted to not performing hand hygiene during the wound care session and acknowledged the risk of causing or worsening an infection. The DON and Administrator confirmed the expectations for hand hygiene and infection control, emphasizing the importance of following standard precautions to protect residents from infections.
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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.
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Nursing homes near Sweeny
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oak Village Healthcare | 14.2 mi | ★★★★★ | 0 | 0 |
| Brazos Healthcare Center | 16.2 mi | ★★★★★ | 4 | 0 |
| Country Village Care | 17 mi | ★★★★★ | 5 | 1 |
| Paradigm At Bay City | 17.4 mi | ★★★★★ | 0 | 0 |
| Creekside Village | 17.5 mi | ★★★★★ | 4 | 0 |
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