Health inspection·January 26, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health and safety of the resident and or other residents for 2 (Resident #16 and #44) of 8 residents observed for accommodation of needs. Residents Affected - Few 1. Resident #16's call light was not placed within reach. 2. Resident #44's call light was not placed within reach. This deficient practice could affect residents who require assistance with care and could result in an emergent need not being addressed. The findings included: 1. Record review of Resident #16's electronic face sheet dated 01/23/2023 reflected he was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: hemiplegia (symptom that involves one sided paralysis) and hemiparesis (one sided muscle weakness) following cerebral infarction (disrupted blood flow to brain causes parts of the brain to die) affecting left non-dominant side, emphysema (type of lung disease that causes breathlessness), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing related problems) and anxiety (nervousness). Record review of Resident #16's quarterly MDS assessment with an ARD of 12/19/2023 reflected he scored a 13/15 on his BIMS which signified he was cognitively intact. Further review reflected under section GG Functional Limitation in Range of Motion, he had impairment on one side of his upper extremity (which included shoulder, elbow, wrist, and hand) and impairment on both sides of his lower extremities (which included hips, knees, ankles, and feet) and required extensive assistance with ADL's. Record review of Resident #16's comprehensive care plan with a revised date of 02/10/2022 reflected Focus .ADL self-care deficits: has ADL self-care deficits and is at risk for further decline in ADL functioning .Interventions/Tasks .Ensure call light is within reach. Observation on 01/23/2024 at 09:34 a.m. of Resident #16 revealed he was lying in bed and his call light was hanging down over the left side of his bed out of reach for his right arm. Observation with the DON on 01/23/2024 at 12:10 p.m. of Resident #16 revealed he was lying in bed and his call light was hanging down over the left side of his bed. Page 1 of 11 455544 455544 01/26/2024 Paradigm at Stevens 204 Walter St Yoakum, TX 77995

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 01/23/2024 at 12:10 p.m. with Resident #16, when asked if he could reach the call light, he raised his right arm and attempted to move it across his body toward his left side and could not reach the call light cord. When asked how he would call for assistance, he stated BEEP, BEEP, BEEP. Interview on 01/23/2024 at 1:47 p.m. with LVN C who was Resident #16's nurse revealed she did not check for the call light when she made rounds, and she should have. She stated Resident #16 could not reach his call light where it was because he could not use his left side. She stated if he needed help quickly, he would have to yell because he could not reach his call light. Interview on 01/23/2024 at 2:00 p.m. with CNA D revealed she noticed the call light when she handed out trays to residents at about 08:30 a.m. She stated she did not think anything of it and continued to hand out morning trays. She stated Resident #16's call light should have been placed on his chest or right side for him to use and to be able to call someone if he needed help. 2. Record review of Resident #44's electronic face sheet dated 01/25/2023 reflected he was admitted to the facility on [DATE]. His diagnoses included: cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain) affecting left dominant side, paraplegia (a specific pattern of paralysis), and bed confinement status (bedridden). Record review of Resident #44's 5-day scheduled MDS assessment dated [DATE] reflected he scored a 12/15 on his BIMS which signified he was cognitively intact. Further review reflected under section GG Functional Limitation in Range of Motion he had impairment on both sides of his upper extremity (shoulders, elbows, wrists, and hands) and impairment on both sides of his lower extremities (hips, knees, ankles, and feet) and required extensive assistance with ADL's. Record review of Resident #44's comprehensive care plan revised 09/05/2023 reflected Focus .is at risk for falls and injuries .Interventions/Tasks .Ensure call light is within reach. Observation on 01/25/2024 at 3:54 pm. accompanied by LVN B as she performed catheter care for Resident #44 revealed , his call light was hanging on the center portion of the back wall at the foot of his bed. In an interview on 01/25/2024 at 3:55 p.m. with Resident #44, he stated that without the call light to get someone In this place, got no choice but to scream. In an interview on 01/25/2024 at 4:00 p.m. with LVN B, she stated that at 09:00 a.m. she had moved things in the room to perform wound care for Resident #44. She stated the call light was hung on the wall and never placed back within his reach. She stated she did check on Resident #44 but must have missed that the call light was not within reach. She stated that it was important for him to be able to contact the staff in case of an emergency. Interview on 01/25/2024 at 4:10 p.m. with CNA D revealed she did check on Resident #44, but never noticed his call light was still hung on the wall from earlier in the day. She stated it was important for Resident #44 to have a call light to call staff in case of an emergency or if he needed care. Interview on 01/26/2024 at 10:00 a.m. with the DON revealed that when staff need to move a resident's call light, they need to put them back. When the staff check on residents, they need to check call light placement. Resident's #16 and #44 can not do things for themselves, and they must have a way 455544 Page 2 of 11 455544 01/26/2024 Paradigm at Stevens 204 Walter St Yoakum, TX 77995

F 0558 Level of Harm - Minimal harm or potential for actual harm to call nursing staff in case of an emergency or change in condition. All staff when entering the room need to check for call light placement. Record review of the facility policy and procedure titled Call Lights-Answering of, revised dated 3/2019 reflected When leaving room, facility staff will place the call light within the resident's reach. Residents Affected - Few 455544 Page 3 of 11 455544 01/26/2024 Paradigm at Stevens 204 Walter St Yoakum, TX 77995

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 8 Residents (Resident #12) whose MDS records were reviewed for accuracy. Residents Affected - Few Resident #12's Quarterly MDS assessment dated [DATE] incorrectly documented the resident had received tube feedings while a resident at the facility. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings included: Record review of Resident #12's face sheet dated 01/25/2024 revealed Resident #12 was admitted to the facility on [DATE] with diagnoses that included: cerebral infarction, chronic obstructive pulmonary disease with (acute) lower respiratory infection, acute respiratory failure with hypoxia, aphasia, cerebellar stroke syndrome, schizophrenia, hyperlipidemia, cerebral aneurysm, and dysphagia, oropharyngeal phase. Record review of Resident #12's Quarterly MDS assessment, dated 12/18/2023, documented the resident while a resident had received tube feedings within the last 7 days. During interview on 01/25/24 at 3:55 p.m. LVN A revealed Resident #12 never had a feeding tube and was not sure why she would have coded him as having one. LVN A further stated it must have been an accident. LVN A stated she was responsible for completing this section of the MDS even though the MDS was a collaborated effort with therapy completing a section, and the DON signing off on the MDS. During interview on 01/26/24 at 10:36 a.m. the DON stated Resident #12 had not had a feeding tube. The DON further stated LVN A did the MDS coding, and it was possibly a typo. The DON stated the coding of the MDS was for billing purposes. The DON further stated he signed the MDS for accuracy, but he just browsed them many times due the number he had to review. Record review of the facility's Nursing Policies and Procedures policy, revised 06/2019, revealed Subject: Minimum Data Set, Policy: It is the policy of this facility that a registered nurse will conduct or coordinate each assessment with the interdisciplinary team. An MDS, which is a comprehensive, accurate, standardized reproducible assessment will be completed for each resident, using the RAI process. Facility staff complete assessment of each resident's needs, strength, goals, life history, and preferences, and offer guidance for further assessment once problems have been identified . Procedures: 9) Each assessment must represent an accurate picture of the resident's status during the observation period of the MDS. When the MDS is completed, only those occurrences during the observation period will be captured on the assessment. If it did not occur during the observation period, it is not coded on the MDS. Record review of the CMS MDS 3.0 Manual dated October 2023 revealed in part, .The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents. The Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident. The MDS 3.0 is part of that assessment process and is required by CMS . 455544 Page 4 of 11 455544 01/26/2024 Paradigm at Stevens 204 Walter St Yoakum, TX 77995

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #18) of 8 residents reviewed for care plans. Resident #18's care plan did not reflect that she required supervision when she smoked. This deficient practice could affect residents who required supervision and could result in an accident or harm. The findings included: Record review of Resident #18's electronic face sheet dated 01/26/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: altered mental status (change in mental function), depression (a common and serious medical illness that negatively affects how one feels, thinks and acts), hemiplegia (paralysis of one side of the body), affecting right dominant side and dementia (a progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). Record review of Resident #18's 5-day MDS assessment dated [DATE] reflected she scored a 6/15 on her BIMS which signified she was moderately cognitively impaired. She required minimal assistance with her care. Record review of Resident #18's comprehensive care plan revised date 01/15/2024 reflected Focus .has a potential for injury related to is a smoker .keeps asking if it's time to go out and smoke when she just got through smoking .residents friend came to see her and brought her cigarettes .Interventions/Tasks .inform resident of smoking policy .orient to smoking area. Record review of Resident #18's Smoking-Safety Screen dated 10/20/2024 performed by LVN A reflected she was Safe to smoke with supervision. Record review of Resident #18's Smoking-Safety Screen dated 01/25/2024 performed by LVN A reflected she was Safe to smoke with supervision. Observation on 01/26/2024 at 08:45 a.m. of Resident #18 outside smoking revealed she had supervision. In an interview on 01/26/2024 at 08:50 a.m. with Resident #18, she stated she had supervision when she smoked. Interview on 01/25/2024 at 3:45 p.m. with LVN A, she stated that Resident #18 smoked, and she did her assessment. She stated Resident #18 required supervision and it should have been reflected in the care plan. She stated it was an important part of Resident #18's care because she must have 455544 Page 5 of 11 455544 01/26/2024 Paradigm at Stevens 204 Walter St Yoakum, TX 77995

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few supervision when she smoked. She stated the resident could get burned or injured if she smoked without supervision. Interview on 01/26/2024 at 10:10 a.m. with the DON, he stated it was important for Resident #18's comprehensive care plan to reflect she required supervision when she smoked because it was part of her care. If she were left unsupervised when she required supervision she could cause injury to herself or others. Record review of the facility policy and procedure titled Care Planning revised 6/2019 revealed It is the policy of this facility that the interdisciplinary team shall develop a comprehensive care plan for each resident. 455544 Page 6 of 11 455544 01/26/2024 Paradigm at Stevens 204 Walter St Yoakum, TX 77995

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 4 residents (Residents #1 and #20) reviewed for incontinent care. While providing incontinent care for Resident #98, CNA E did not return Resident #1's foreskin to the normal position. This deficient practice could place residents at-risk for infection, paraphimosis (urologic emergency in uncircumcised males) and skin break down due to improper care practices. The findings were: Record review of Resident #98's electronic face sheet dated 01/24/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), hemiplegia (paralysis of one side of body) and hemiparesis (one sided muscle weakness) following cerebral infarction affecting left non-dominant side, and spinal stenosis (a narrowing of the spinal canal in the lower part of the back) cervical region (neck area of the spine). Record review of Resident #98's admission MDS assessment dated [DATE] reflected he scored a 15/15 on his BIMS which signified he was cognitively intact. He was frequently incontinent of bladder and always incontinent of bowel. He required extensive assistance with ADL's. Record review of Resident #98's comprehensive care plan revised 01/20/2024 reflected Focus .has bowel and bladder incontinence. Staff assist with peri care .clean peri-area with each incontinence episode. Observation on 01/24/2024 at 2:33 p.m. of C NA E performance of incontinent care for Resident #98 revealed she pulled the resident's foreskin on his penis back and did not return it to the normal position. Interview on 01/24/2024 at 2:35 p.m. with C NA E, she stated she was a medication aide and she drove the van. She did not usually provide direct care to the residents and had a competency checklist done in 2022. She stated she realized it was important to pull Resident #98's foreskin back to clean underneath and did not think to return the foreskin to the normal position. This could result in prevention of blood circulation to the area. Interview on 01/26f/2024 at 10:00 a.m. with the DON, he stated C NA E needed to put Resident #98's foreskin back to the normal position because of the potential complications such as infection and prevention of blood circulation to the area. He stated he needed to include the medication aides in the competencies because they were prone to provide direct care for the residents. He stated he could not locate a competency checklist for male peri care for C NA E. Review of the facility competency checklist titled Peri-Care (undated) reflected Returns foreskin to normal position. 455544 Page 7 of 11 455544 01/26/2024 Paradigm at Stevens 204 Walter St Yoakum, TX 77995

F 0690 Record review of the facility policy and procedure titled Perineal/Incontinent Care revised 6/2019 reflected For male patient/resident .Return foreskin to its natural position. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 455544 Page 8 of 11 455544 01/26/2024 Paradigm at Stevens 204 Walter St Yoakum, TX 77995

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for 1 (Resident #16) of 2 residents reviewed for oxygen therapy. Residents Affected - Few LVN B turned off Resident #16's oxygen concentrator and did not return to turn it back on. This deficient practice could affect residents on oxygen therapy and could result in low or high oxygen levels in the blood and cause respiratory distress. The findings included: 1. Record review of Resident #16's electronic face sheet dated 01/23/2023 reflected he was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: hemiplegia (symptom that involves one sided paralysis) and hemiparesis (one sided muscle weakness) following cerebral infarction (disrupted blood flow to brain causes parts of the brain to die) affecting left non-dominant side, emphysema (type of lung disease that causes breathlessness), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing related problems) and anxiety (nervousness). Record review of Resident #16's quarterly MDS assessment with an ARD of 12/19/2023 reflected he scored a 13/15 on his BIMS which signified he was cognitively intact. Further review reflected under section GG Functional Limitation in Range of Motion, he had impairment on one side of his upper extremity (which included shoulder, elbow, wrist, and hand) and impairment on both sides of his lower extremities (which included hips, knees, ankles, and feet) and required extensive assistance with ADL's. Record review of Resident #16's comprehensive care plan with a revised date of 02/28/2022 reflected Focus .shortness of breath .is at risk for respiratory distress/failure and increased episodes of SOB r/t emphysema .Interventions/Tasks .Apply O2 per order. Record review of Resident #16's Active Orders for January 2024 reflected Oxygen at 2.5 L/min per nasal cannula continuously .active as of 1/17/24. Record review of Resident #16's MAR for January 2024 reflected,. Oxygen at 2.5 L/min per nasal cannula continuously, and it was initialed off (administered) by LVN C on 01/23/2024 at 06:00 a.m. Observation on 01/23/2024 at 09:34 a.m. of Resident #16 revealed he was lying in bed and his oxygen concentrator was not turned on. He had a nasal canula in his nostrils. Observation with the DON on 01/23/2024 at 12:10 p.m. of Resident #16 revealed his oxygen concentrator was off and the DON turned it on. Interview on 01/23/2024 at 12:10 p.m. with Resident #16, when asked if he had shortness of breath, he stated yes, but he said he was OK. Interview on 01/23/2024 at 12:30 p.m. with the DON revealed, he did not know why Resident #16's 455544 Page 9 of 11 455544 01/26/2024 Paradigm at Stevens 204 Walter St Yoakum, TX 77995

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few oxygen concentrator was off. He stated that he needed to follow-up on it because the resident could have respiratory distress. He stated the nurses were responsible to check the oxygen concentrators. Interview on 01/23/2024 at 1:47 p.m. with LVN C who was Resident #16's nurse revealed she turned Resident #16's oxygen concentrator off when she checked on him at 08:00 a.m. because it was making loud noises. She stated she intended to bring in another one or have it checked. She said she was busy and forgot about it. She stated she checked his oxygen levels, and he was fine, and she should have placed him back onto oxygen because he could have had respiratory distress. Interview on 01/23/2024 at 2:00 p.m. with C NA D revealed she noticed Resident #16's oxygen concentrator was turned off' when she handed out trays to residents at about 11:30 a.m. and she went and told LVN C. She stated she thought LVN C had taken care of the oxygen. She said it was important to notify the nurse of any changes or issues with a resident. She stated without his oxygen he could have respiratory distress. Record review of the facility policy and procedure titled Oxygen Therapy: General Administration and Care revised 8/2019 reflected It is the policy of this facility that the facility will provide oxygen therapy .review physician's order on the chart .modality, liters, and frequency. 455544 Page 10 of 11 455544 01/26/2024 Paradigm at Stevens 204 Walter St Yoakum, TX 77995

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. Residents Affected - Some The facility failed to ensure dietary staff with facilal hair, were wearing beard restraints. These failures could place resident who received meals and/or snacks from the kitchen at risk for food borne illness. The findings were: Observations on 01/25/24 11:28 a.m. revealed DA not wearing beard restraint/beard guard with approximately 1/2 inch to inch beard to his chin. DA was further observed taking dishware from the dish room area throughout the kitchen and hanging cooking utensils above the food prep table near the steam table. Observations on 01/25/24 at 11:39 a.m. revealed DA washing cooking utensils and pans in the 3 compartment sink without a beard restraint/beard guard. During an interview on 01/25/24 at 11:41 a.m. the DM stated DA should have been wearing a beard guard and that hair restraints should be worn anytime someone was in the kitchen. DM further stated by not wearing a beard guard it could cause food contamination. DM provided dietary aide with a face mask to use to cover his facial hair. During an interview on 01/25/24 at 11:42 a.m. the DA stated he should have been wearing a beard guard. The DA further stated by not wearing a beard guard it could allow hair to fall in the food on dishes and spread germs. Record review of dietary staff's food handlers' certificates revealed the staff in mention had taken the food handler's course. DA's food handlers certificate revealed an issued date of 08/21/2023. Record review of the facility's policy titled Nutrition Services Policies and Procedures, revised 06/2019, revealed Subject: Dress Code, Policy: The Nutrition/Culinary Services Department employees will adhere to a facility dress code that facilitates safe, sanitary meal production and service, and will present a professional appearance. Procedures: Culinary staff involved in food production adheres to the department dress code that includes: 6. Appropriate hair restraints (such as hats, hair covers or nets, beards restraints) while involved food production activities. 455544 Page 11 of 11