Cycle 1
Health 2025-12-11 · Fire 2025-12-11
16 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Houston, TX
Paradigm Northwest
1-star overall rating with 1-star inspections with $51,400 in total fines with 16 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
17600 Cali Dr, Houston, TX
(281) 440-9000
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
148
Certified beds
Average residents
100
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Paradigm Healthcare
Operator or chain grouping
Approved since
1987-09-01
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.19
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.05
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.00
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.24
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.24
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.82
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.18
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.17
CMS adjusted RN staffing hours
Adjusted total hours
2.84
CMS adjusted total nurse staffing hours
Case-mix index
1.56
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,496
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.97
Composite VBP score used to determine payment impact.
Payment multiplier
0.9810
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
1.45
Performance 57.73% · Measure score 1.45 · Achievement 1.45 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.94
Baseline 3.61 hours · Performance 3.34 hours · Measure score 0.94 · Achievement 0.94 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.26% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 11.43% · Lower 95% interval 6.75% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 33 · Denominator 33 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 33 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 33 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 136 |
| Staff flu vaccination coverage | 26.44% |
42%
15.6 pts worse
|
Numerator 55 · Denominator 208 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 20 · Denominator 20 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
97.1%
2.6 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.9% · 4Q avg 99.7% |
| 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 | 0.8% |
3.3%
2.5 pts better
|
3.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.1% · Q3 1.1% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 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 who lose too much weight | 1.0% |
3.3%
2.3 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.3% · Q3 0.0% · Q4 1.2% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.6% |
18.9%
0.3 pts better
|
19.6%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 17.3% · Q3 12.5% · Q4 21.8% · 4Q avg 18.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.0% |
10.8%
1.2 pts worse
|
16.7%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 12.1% · Q3 9.4% · Q4 16.4% · 4Q avg 12.0% · 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 | 8.3% |
15.4%
7.1 pts better
|
16.3%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 7.2% · Q3 0.0% · Q4 18.4% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.6% |
16.1%
7.5 pts better
|
14.9%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 7.6% · Q3 1.5% · Q4 20.8% · 4Q avg 8.6% · 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 | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 3.8% |
15.0%
11.2 pts better
|
19.8%
16 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 1.1% · Q4 11.8% · 4Q avg 3.8% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
4.2%
0.2 pts worse
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 4.3% · Q3 4.7% · Q4 6.4% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.9% |
89.7%
3.2 pts better
|
81.7%
11.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.3% · Q2 95.8% · Q3 88.2% · Q4 90.8% · 4Q avg 92.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.0% |
12.0%
1 pts better
|
12.0%
1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.0% · Observed 15.0% · Expected 15.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.8% |
88.0%
7.8 pts better
|
79.7%
16.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.3% |
25.9%
8.4 pts worse
|
23.9%
10.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.3% · Observed 55.0% · Expected 38.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-26 · Fire 2024-09-26
8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-07-28 · Fire 2023-07-28
6 health deficiencies
Top issue: Environmental (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-12-16
E · Potential for more than minimal harm
2025-12-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-12-16
E · Potential for more than minimal harm
2025-12-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-12-16
E · Potential for more than minimal harm
2025-12-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-12-16
E · Potential for more than minimal harm
2024-09-26
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-10-14
E · Potential for more than minimal harm
2023-07-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-07-26
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-21
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Not marked corrected
D · Potential for more than minimal harm
2025-12-11
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-12-16
D · Potential for more than minimal harm
2025-12-11
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-12-16
D · Potential for more than minimal harm
2025-12-11
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 2025-12-16
D · Potential for more than minimal harm
2025-12-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-12-16
D · Potential for more than minimal harm
2025-12-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-12-16
D · Potential for more than minimal harm
2025-12-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-16
E · Potential for more than minimal harm
2025-12-10
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 2025-12-11
D · Potential for more than minimal harm
2025-12-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-12-11
J · Immediate jeopardy
2025-08-18
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 2025-08-22
J · Immediate jeopardy
2025-08-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-22
J · Immediate jeopardy
2025-08-12
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 2025-08-07
D · Potential for more than minimal harm
2025-08-12
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 2025-08-15
E · Potential for more than minimal harm
2025-08-05
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-06-12
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 2025-06-13
D · Potential for more than minimal harm
2025-03-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-25
J · Immediate jeopardy
2024-12-20
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 2025-01-10
E · Potential for more than minimal harm
2024-09-26
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 2024-10-18
D · Potential for more than minimal harm
2024-09-26
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-18
C · Minimal harm
2024-09-26
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-13
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 2024-09-26
D · Potential for more than minimal harm
2024-09-13
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-05-08
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 2024-05-23
J · Immediate jeopardy
2024-02-14
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 2024-02-19
D · Potential for more than minimal harm
2024-02-14
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 2024-02-19
E · Potential for more than minimal harm
2023-07-28
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 2023-08-31
E · Potential for more than minimal harm
2023-07-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-07-28
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-07-28
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-08-31
Penalties and ownership
What sits behind the stars
$13,679
2025-08-05
Fine
Fine · fine $13,679
Fine
$13,679
2025-08-05
Fine
Fine · fine $13,679
Fine
$14,433
2024-12-20
Fine
Fine · fine $14,433
Fine
$9,609
2024-02-14
Fine
Fine · fine $9,609
Fine
Ownership
Oakbend Medical Center
5% Or Greater Direct Ownership Interest · Organization
Freudenberger, Joseph
Corporate Officer · Individual
Freudenberger, Joseph
W-2 Managing Employee · Individual
Northwest Nursing & Rehabilitation LLC
Operational/Managerial Control · Organization
Shkop, Aharon
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Park Manor of Cypress Station
Houston, TX
1-star overall rating with 1-star inspections with $33,976 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
The Heights Of North Houston
Houston, TX
3-star overall rating with 3-star inspections with $39,207 in total fines with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Villa Toscana At Cypress Woods
Houston, TX
2-star overall rating with 2-star inspections with $37,827 in total fines with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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