Cycle 1
Health 2026-01-22 · Fire 2026-01-22
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Missouri City, TX
Paradigm At First Colony
1-star overall rating with 1-star inspections with $211,113 in total fines with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
4710 Lexington Blvd, Missouri City, TX
(281) 499-4710
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
150
Certified beds
Average residents
106
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Paradigm Healthcare
Operator or chain grouping
Approved since
1989-04-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
18 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.50
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.72
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.42
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.22
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.05
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
3.49
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
80%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,278
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.19
Composite VBP score used to determine payment impact.
Payment multiplier
0.9834
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.83
Baseline 21.67% · Performance 21.05% · Measure score 0.83 · Achievement 0.83 · Improvement 0.83
Healthcare-associated infections
5.01
Baseline 9.63% · Performance 7.08% · Measure score 5.01 · Achievement 2.53 · Improvement 5.01
Total nurse turnover
2.50
Baseline 74.15% · Performance 59.38% · Measure score 2.50 · Achievement 1.05 · Improvement 2.50
Adjusted total nurse staffing
1.33
Baseline 3.27 hours · Performance 3.46 hours · Measure score 1.33 · Achievement 1.33 · Improvement 0.25
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.03% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 56 · Observed rate 14.29% · Lower 95% interval 7.67% |
| Discharge to community | 42.25% |
50.57%
8.3 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 25% · Lower 95% interval 27.42% |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 43 · Denominator 43 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 43 |
| Discharge self-care score | 65.38% |
53.69%
11.7 pts better
|
Numerator 17 · Denominator 26 |
| Discharge mobility score | 53.85% |
50.94%
2.9 pts better
|
Numerator 14 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 11.63% |
2.29%
9.3 pts worse
|
Numerator 5 · Denominator 43 · Adjusted rate 7.85% |
| Healthcare-associated infections requiring hospitalization | 7.08% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 28 · Observed rate 7.14% · Lower 95% interval 3.53% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 98 |
| Staff flu vaccination coverage | 30.11% |
42%
11.9 pts worse
|
Numerator 56 · Denominator 186 |
| Discharge function score | 76.92% |
56.45%
20.5 pts better
|
Numerator 20 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 4.55% |
25.2%
20.6 pts worse
|
Numerator 1 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.1
0.2 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.6 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 5.7 |
2.1
3.6 pts worse
|
1.8
3.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.7 · Observed 5.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
97.1%
0.6 pts better
|
93.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.8% · Q3 95.9% · Q4 98.0% · 4Q avg 97.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
3.3%
1.5 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 2.1% · Q3 2.0% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
2.7%
1.9 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 1.7% · Q4 0.0% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
3.3%
2.6 pts worse
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 7.0% · Q3 2.4% · Q4 2.4% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.0% |
18.9%
2.9 pts better
|
19.6%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.6% · Q2 22.1% · Q3 14.0% · Q4 15.3% · 4Q avg 16.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.4% |
10.8%
11.6 pts worse
|
16.7%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 22.4% · Q3 23.2% · Q4 20.0% · 4Q avg 22.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.2% |
15.4%
10.2 pts better
|
16.3%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 2.7% · Q3 2.4% · Q4 2.3% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.1% |
16.1%
5 pts better
|
14.9%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 9.9% · Q3 9.3% · Q4 4.2% · 4Q avg 11.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
0.8%
0.5 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.0% |
15.0%
4 pts better
|
19.8%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 9.8% · Q3 17.6% · Q4 8.5% · 4Q avg 11.0% |
| Percentage of long-stay residents with pressure ulcers | 9.2% |
4.2%
5 pts worse
|
5.1%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 8.8% · Q3 10.7% · Q4 6.5% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.3% |
89.7%
6.6 pts better
|
81.7%
14.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.0% · Q3 99.1% · Q4 87.1% · 4Q avg 96.3% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.5%
0.5 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 1.8% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.1% |
88.0%
9.1 pts better
|
79.7%
17.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-24 · Fire 2024-10-24
20 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-09-08 · Fire 2023-09-08
17 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2026-01-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2026-01-31
E · Potential for more than minimal harm
2026-01-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2026-01-25
E · Potential for more than minimal harm
2026-01-22
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2026-01-25
F · Potential for more than minimal harm
2024-10-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-10-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-10-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-10-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-10-24
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-10-02
E · Potential for more than minimal harm
2024-10-24
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2024-10-01
F · Potential for more than minimal harm
2023-09-08
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-09-09
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-01
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2025-12-15
D · Potential for more than minimal harm
2025-11-14
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Not marked corrected
E · Potential for more than minimal harm
2025-09-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-09-23
D · Potential for more than minimal harm
2025-06-01
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-06-05
K · Immediate jeopardy
2024-11-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-04
K · Immediate jeopardy
2024-11-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-04
C · Minimal harm
2024-11-19
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-11-20
C · Minimal harm
2024-11-19
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-11-20
K · Immediate jeopardy
2024-10-24
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-10-31
F · Potential for more than minimal harm
2024-10-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-31
E · Potential for more than minimal harm
2024-10-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-10-31
E · Potential for more than minimal harm
2024-10-24
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-10-24
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-10-24
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-10-24
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-10-24
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-10-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-10-24
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-10-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-10-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-31
C · Minimal harm
2024-10-24
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-08-21
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-28
D · Potential for more than minimal harm
2024-07-25
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-12
D · Potential for more than minimal harm
2024-07-25
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-02-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-12
D · Potential for more than minimal harm
2024-02-08
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-02-12
E · Potential for more than minimal harm
2023-11-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-11-02
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-11-03
E · Potential for more than minimal harm
2023-09-08
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-09-15
E · Potential for more than minimal harm
2023-09-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-09-08
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-09-08
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-09-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-09-08
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-09-15
K · Immediate jeopardy
2023-08-15
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-08-22
K · Immediate jeopardy
2023-08-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-09-15
J · Immediate jeopardy
2023-08-15
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-08-22
J · Immediate jeopardy
2023-08-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-22
J · Immediate jeopardy
2023-08-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-18
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-07-25
D · Potential for more than minimal harm
2023-04-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-21
Penalties and ownership
What sits behind the stars
$19,838
2024-11-27
Fine
Fine · fine $19,838
Fine
$44,721
2024-10-24
Fine
Fine · fine $44,721
Fine
$146,554
2023-08-15
Fine
Fine · fine $146,554
Fine
Ownership
Oakbend Medical Center
5% Or Greater Direct Ownership Interest · Organization
Beard, Barry
Corporate Director · Individual
Council, Jeff
Corporate Director · Individual
Crayton, Tom
Corporate Director · Individual
Freudenberger, Joseph
Corporate Officer · Individual
Freudenberger, Joseph
W-2 Managing Employee · Individual
Martin, Melissa
Corporate Director · Individual
Mcclamroch, James
Corporate Director · Individual
Mefford, Ruthanne
Corporate Director · Individual
Murray, Mark
Corporate Director · Individual
Petrosewicz, Norma
Corporate Director · Individual
Ssc Missouri City Operating Company LLC
Operational/Managerial Control · Organization
Tape, May
Corporate Director · Individual
Uthman, Edward
Corporate Director · Individual
Nearby options
Other facilities in reach
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Park Manor of Quail Valley
Missouri City, TX
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Chelsea Gardens
Missouri City, TX
4-star overall rating with 4-star inspections with $56,103 in total fines with 3 fire-safety deficiencies in the latest cycle
#3
Windsor Quail Valley Post-Acute Healthcare
Missouri City, TX
2-star overall rating with 3-star inspections with $52,036 in total fines with 3 recent health deficiencies
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