Health inspection·February 9, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately to the State Survey Agency, for one closed record resident (CR #99) of 16 reviewed for abuse and neglect. The facility failed to report to the state agency when an incident with CR #99 was found on the floor unresponsive. This failure affected one closed record resident and placed an additional 42 residents who reside at the facility at increased risk for abuse and neglect and unreported injuries. The findings included: CR #99 Record review of CR #99's face sheet revealed he was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. CR #99 was discharged from the facility on [DATE] to the funeral home. His diagnoses included: chronic systolic heart failure (heart can not pump blood efficiently, chronic kidney disease, stage 3 (kidney damage and does not filter blood as well as it should), nonischemic myocardial injury (an acute or chronic heart injury), hyperlipidemia (elevated cholesterol), cirrhosis of the liver (liver is scared and permanently damaged),hypoxemia (low oxygen level), hypertension (high blood pressure), type 2 diabetes mellitus, aortic aneurysm (balloon-like bulge in the heart), ventricular tachycardia (abnormal heart rhythm) and nonrheumatic tricuspid insufficiency (heart valve disease). Record review of CR #99's Baseline Care Plan dated [DATE] revealed .B. Communication: resident could easily communicate with staff and the resident understood staff. E. Advanced Directives/ Code Status/ admission and D/C Goals: Full code status. Discharge goal was to return to the community. Functional Abilities and Goals- Mobility: One-person physical assist with bed mobility and transfers. Set up help for walking in the room. Health Conditions A. Oxygen therapy while a resident. CR #99 Cognition: Alert and cognitively intact. Safety Risks: Identified no history of falls. CR required dialysis. Record review of CR #99's Order Summary Report active as of [DATE] revealed orders for: -Advanced directives: full code Page 1 of 17 455582 455582 02/09/2023 Paradigm at Bay City 1800 13th St Bay City, TX 77414

F 0609 -Discharge potential: fair Level of Harm - Minimal harm or potential for actual harm -Required a skilled nursing facility. Residents Affected - Few Interview on [DATE] at 2:15 p.m. with the Administrator said CR #99 death was not called into the state agency because he had multiple health conditions and his death was expected. He said that CR's incident was talked about in the morning meeting with the IDT and it was concluded because of his health conditions it was not necessary to notify the state entity. The Administrator said he calls in the facility reportable incidents into the state. He said he also ensures that the investigation was completed in a timely manner, Record review of CR #99's electronic Progress Note by LVN C dated [DATE] at 3:41 p.m. revealed Nursing staff was alerted to the room by RCS (Residential Care Support) with reports that the patient was found on the floor. Patient was found face down on the floor and responsive. During transfer, patient appeared to not be breathing. Patient is a full code. CPR was initiated. EMS notified. EMS ruled TOD (time of death) at 11:31 a.m. Resident's family member sister and MD have been notified. The funeral home has been called to receive the patient body. Interview on [DATE] at 3:10 p.m. with the DON and Administrator. The DON said she spoke with LVN C earlier that day ([DATE]) and the LVN C said the progress note finding for CR #99 on the floor responsive should have been unresponsive. The DON explained that LVN C had told her it was a typo. The DON said the LVN said she accidently wrote responsive instead of unresponsive. She said an incident report was completed with the accurate note by LVN C. She said LVN C followed the fall protocol assessment which would include a neuro assessment and vital signs and that's when she identified the resident was not responsive. She said the incident with CR #99 was not unexpected even though he was full code status because he was noncompliant with his care, and he had several major health problems. She said he had recently been in and out of the hospital and the nursing facility because of his health status and noncompliance. She said the facility discussed the incident but did not call it into the state because it did not meet the state requirements. The DON said a root cause was not completed due to the incident with CR #99. The administrator said the nursing facility follows the state policy and procedure guidelines when to report possible allegations of abuse or neglect. A record review of an untitled document dated [DATE] at 11:03 a.m. for CR #99 written by LVN C read in part . Incident description: Nursing staff was alerted to the room by the staff with reports that the patient was found on the floor. Upon assessment , patient was not breathing and no pulse noted. CPR was initiated. EMS notified. EMS ruled time of death at Record review of assessment completed on 11:31 a.m. Resident unable to give description. Immediate action taken was resident was assessed by nurse. CPR with AED initiated. EMS called. Once EMS arrived. EMS led CPR. EMS ruled TOD at 11:31 a.m. No injuries observed at the time of the incident . Resident noncompliant with care, history of heart failure . No witnesses found . Unsigned and undated. In a telephone interview on [DATE] at 10:13 a.m. with CNA B said on the day of the incident, on [DATE] around 10ish she was in CR #99's room around to help him get ready before he had left for dialysis . She said she assisted him with getting dressed and helped him sit up on the side of the bed. She said she left the resident sitting on the side of the bed. CNA B said nothing seemed different that day for CR #99. She said he was alert and orientated and was able to talk with her while getting him ready. The CNA said she was making rounds around 11:00 a.m. and saw the resident lying face down on the floor unresponsive. She said there was no one else in the room when she found him. She said she stayed with CR #99 and called out into the hallway for staff/ nurse assistance. CNA B said LVN C 455582 Page 2 of 17 455582 02/09/2023 Paradigm at Bay City 1800 13th St Bay City, TX 77414

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few came and started CPR quickly. She said she could not remember for sure who were the other staff that assisted but the AED and 911 was called quickly. She said she left the room when EMS arrived. In a telephone interview on [DATE] at 10:20 a.m. with LVN C said on [DATE] that morning she heard a staff call out for assistance. She said she stopped what she was doing and went immediately down the hallway to CR #99 room. She said she saw CR #99 unresponsive lying on his side with his nasal canula oxygen still in his nose and on. LVN C said CR #9 had a faint pulse so she called for assistance and then turned him on his back because he was not breathing. She said another LVN assisted by calling 911 and had brought the AED. She said she assisted with the CPR until EMS arrived. Surveyor questioned the LVN about the Progress Note she wrote on [DATE] at 3:41 p.m., she said it was a mistake on her part she said when she went into the resident room and found the resident on the floor he was unresponsive already. She said the resident was in poor health, he had been refusing care including dialysis. She said when she seen saw him earlier that day CR #99 was agitated but unsure of the cause because there was no concerns. LVN C said she notified the sister after the incident. She said it was a difficult time notifying the family because his death was unexpected and she had to make a decision on where to send the resident's body. A record review of facility policy named Fall Management dated 1/ 2019 read in part .It is the policy of this facility to evaluate extent of injury after a fall, prevent complications and to provide emergency care. Each resident will be evaluated upon admission, quarterly, after a fall and as needed by the licensed nurse to evaluate his/her individual level of risk. The interdisciplinary team will review the fall risk evaluation completed by the nursing department and if appropriate, a fall prevention protocol will be initiated . Note: If condition from fall is life threatening, the nurse shall initiate EMS stat and then place a call to physician, hospice, and family/ responsible party . Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred . A record review of facility policy titled State Reporting and PCE guidelines: Ensuring Compliance undated read in part . Refer to Texas Department of Aging and Disability Services for Texas state reporting guidelines The purpos of the notification is to ensure that the issue is reviewed from all angles and ensure the root cause of the issue is identified and proper intervention is put into place prior to report if possible . In most cases the facility Administrator, DON and support team should discuss incidents to determine if it meets reporting criteria prior to the report being made. Resident Property and Other incidents that a Nursing Facility must report to the Health and Human Services Commission dated [DATE] revealed the nursing facility must report to HHSC the following types of incidents, in accordance with applicable . . 455582 Page 3 of 17 455582 02/09/2023 Paradigm at Bay City 1800 13th St Bay City, TX 77414

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 observations, interviews, and record reviews, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 4 residents (Residents #95) reviewed for indwelling catheters. -The facility failed to ensure Resident #95 Foley catheter (F/C) (tubing inserted into the bladder to drain urine) was secured to her leg to prevent stress or pulling on the catheter site. -The drainage urine bag was placed on resident's bed area instead of below bladder to prevent urine from flowing back into the bladder. The drainage bag was about 300 cc ( cubic centimeter) full, pulling on the catheter tube. These failures could place residents at risk for discomfort, urethral trauma, and urinary tract infections. Findings include: Review of Resident #95's face sheet dated 12/09/22, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of malignant neoplasm(cancer) of esophagus, malignant neoplasm of part of bronchus or lung, chronic obstructive pulmonary disease, muscle wasting and atrophy, abnormalities of gait and mobility, urinary tract infection, dysphagia (difficulty swallowing), gastro-esophageal reflux disease ( gastric reflux) without esophagitis, vitamin deficiency, retention of urine and covid-19. Record review of Resident #95's admission MDS, dated [DATE], revealed a BIMS score of 15 out of 15, which indicated the resident's cognition was not impaired. Resident #95's functional status revealed she required extensive assistance with bed mobility, transfer, dressing, and personal hygiene. Resident #95 was always of incontinent of bowel and continent of bladder using an indwelling catheter. Record review of physician order dated 12/13/2022 revealed use catheter securing device to reduce excessive tension on the tubing and facilitate urine flow. Rotate site of securement daily and as needed every shift. Review of Resident #95's care plan initiated 12/22/22 revealed plan for presence or care for Foley catheter on Resident #95. Record review of Resident #95's care plan, dated 12/22/2022, revealed: -Focus: Resident #95 admitted with an indwelling foley catheter due to obstructive uropathy. -Goal: The resident will be and remain free from catheter-related trauma through the review date . -Interventions: Check tubing for kinks and ensure that collection bag was not touching the floor upon routine rounds, Monitor and document for pain or discomfort due to the catheter . Observation on 2/7/2023 at 6:30 AM during catheter care for Resident #95 by CNA A revealed his 455582 Page 4 of 17 455582 02/09/2023 Paradigm at Bay City 1800 13th St Bay City, TX 77414

F 0690 Foley catheter tubing over his right leg not secured in place with a leg strap. Level of Harm - Minimal harm or potential for actual harm Observation of Resident #95 for incontinent and indwelling catheter care on 02/08/23 at 9:20 AM performed by C.NA CNA A. revealed Resident #95 was lying in bed with large bowel movement. Resident #95 had a Foley catheter that was not secured to the resident's leg. CNA A placed the Foley bag on the bed with 300 cc of urine, then opened Resident #95's brief with large bowel movement with catheter tubing stained with fecal matter. C.CNA A using wet wipes, cleaned Resident #95's indwelling catheter, CNA A using the wet wipes cleaned the F/C ( Foley Catheter) from outward tubing to insertion site. Residents Affected - Few Interview with CNA A on 02/08/23 at 11:30 AM, regarding incontinent and F/C care, she said she did a good job and for indwelling catheter not secured, she said it was the nurses that secured the catheter and she was going to let the nurse know. CNA A stated the urine bag on the bed can flowed back to Resident #95's bladder because the Foley bag was at the same level as the bladder and could cause infection. CNA A said I messed up Interview with RN E on 02/08/23 at 5:15 PM, she said she was responsible for Resident #95 during the morning shift. She was not aware that Resident #95's Foley catheter was not secured to his leg. She stated it was the facility protocol that the Foley catheter be strapped to the resident's leg. RN E said the loose Foley tubing could cause physical trauma to Resident #95. RN E said she has not check Resident #95's catheter, C.NA A brought it to her attention. Interview with the DON on 02/08/23 at 5:30 PM she said she was not aware of the issues regarding Resident #95 Foley catheter. The DON explained it was the facility policy and protocol to strap the Foley catheter. She said she did not know why the C.NA A placed indwelling catheter on Resident #95's bed while performing incontinent care. DON said she and the ADON was responsible for staffs training. She stated the nurse was also responsible for ensuring the catheter was strap. The Plan was to in-service to make sure the CNA know they can also replace the leg strap on the indwelling catheter. Interview on 02/09/2023 at 8:33 AM the Administrator stated his expectation was that the catheters were secured in place. The Administrator stated he did not know why this occurred; the staff was normally very good about making sure the catheter straps were on. He continued and stated the risk of not securing the tube was it could result in infection or trauma. Record review of CNA A in-services dated 11/1/22 revealed skilled check done for peri-care and catheter care-urinary .14. (Using a clean washcloth, clean catheter tubing using one cloth per stroke, in a circular motion. Clean from the most proximal (closest to the body) to the most distal (farthest for the body). Continue cleaning in this manner until tubing is clean. Skilled check done 11/1/22 for peri-care and catheter care-urinary revealed C.NA A passed . Review of Lippincott Manual of Nursing Practice 9th Edition 2009, page 783 indicated the following regarding securing a urinary catheter: General Considerations: .Secure the indwelling catheter to patient's thigh using tape, strap, adhesive anchor, or other securement device. Where should the urinary drainage bag Foley bag be kept? 455582 Page 5 of 17 455582 02/09/2023 Paradigm at Bay City 1800 13th St Bay City, TX 77414

F 0690 Always keep your urine bag below your bladder, which is at the level of your waist. This will prevent urine from flowing back into your bladder from the tubing and urine bag, which could cause an infection. Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy on Foley catheter dated 06/2019 reflected the following: Residents Affected - Few Indwelling catheter evaluation and management Procedure . 10: Observe urethral meatus and surrounding tissues for inflammation, swelling and discharge. Ask resident if he/she is experiencing any pain or discomfort in the area . 12. Cleanse area well at catheter insertion, taking care not to pull on catheter or advance further into urethra 13. Using a clean cloth, clean Foley tubing using one stroke per cloth in a circular motion and cleaning from closet to the body outward. Continue to wipe until clean . Bladder incontinence data collection/evaluation . 2) Document care plans goals and interventions 3) Anchor the catheter to prevent excessive tension and facilitate flow of urine . . 455582 Page 6 of 17 455582 02/09/2023 Paradigm at Bay City 1800 13th St Bay City, TX 77414

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 2 residents (Resident #37) reviewed for gastrostomy tube management. The facility failed to ensure Resident #37's head of bed was elevated at a minimum of 30-degree angle during enteral feeding ( a way to deliver food directly to the stomach) via gastrostomy tube (G-tube) (A tube directly inserted through the skin to the stomach to deliver nutrition). RN B failed to administer Resident #37's G-tube water flush and medications via gravity flow through the piston. This failure could place residents who receive enteral feedings by G-tube at risk for injury, aspiration into the lungs ( fluid or food enter the lungs accidently), decreased quality of life, hospitalization and decline in health. Findings include: Record review of Resident #37's face sheet dated 2/9/23 revealed a 56- year-old-male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included motor vehicle accident, cognitive communication deficit, traumatic brain injury (an injury to the brain or brain tissue), and aphasia (a brain disorder causing trouble with speaking or understanding other people speaking) . Record review of Resident #37's Comprehensive MDS dated [DATE] revealed the resident's BIMS score was unable to be scored. Cognitive skills for daily decision making identified Resident #37 as severely impaired. Nutritional Status section identified use of a feeding tube. Record review of Resident #37's Care Plan undated revealed : Focus: Resident #37 requires PEG tube feeding related to aphonia. Intervention: Check for tube placement and gastric contents/ residual volume per facility protocol and record. Elevate head of bed 30-45 degrees (semi-Fowler's position) during feedings and at least 1 hour after feeding to prevent aspiration pneumonia (pneumonia that is caused by something other than air being inhaled into respiratory tract.). Focus: Resident #37 has the potential for nutritional problem related to nothing by mouth diet restrictions. Feedings via PEG tube. Interventions: Administer Jevity 1.5 at 60ml/ hour for 22 hours per day (may allow 2 hours off for ADL's). Water flushes 300ml 4 times a day. Administer medications as ordered. Record review of Resident #37's February 2023 Physician Order Summary dated 02/09/2023, revealed Enteral Feeding- head of bed every shift encourage resident to keep head of bed elevated at 30 degrees or higher with active feeing administration. Enteral feeding- flush every shift with 5-30ml of free water before and after each intermittent feeding, medication administration, when feeding is interrupted and at least every shift. Resident #37 had an order for Docusate Sodium liquid 10mg/ 10ml, give 10ml enterally two times a day for bowel management. 455582 Page 7 of 17 455582 02/09/2023 Paradigm at Bay City 1800 13th St Bay City, TX 77414

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 2/8/2023 at 4:01 p.m., accompanied by RN B Resident #37 was observed in bed with the head of bed (HOB) slightly elevated, he was awake but nonverbal. Resident #37's tube feeding was on hold per pump. Surveyor measured Resident's #37 head of bed by the iPhone clinometer (precise slope measurement tool for iPhone) identified the resident's head of bed was elevated to 23 degrees. Interview and observation on 2/8/23 at 4:01 p.m. with RN B stated Resident #37's HOB was elevated but she was unsure of the degree of elevation. She said the resident had an order to have his head of bed elevated to at least 30 degrees while on his feeding and taking medications. She said she had not measured the resident's head of bed because the beds did not have an angle finder like the hospital beds. The nurse said she did not know how to measure the resident's bed. RN B stated the nurses were responsible for making sure the resident was in the correct position and the HOB elevated when making rounds. The risk to the resident was he could aspirate (fluid or food enter into the lungs). RN B said she just stopped the feeding pump before preparing the resident's medications. She said she reviewed the MAR to ensure the resident received the correct medications. An observation by the revealed RN B used the g-tube plunger and pushed the water flush and medication with the plunger verses allowing the flush and medication to go in via gravity. After the medication and water flush RN B was asked how she was supposed to administer water flushes and medications. The nurse said she did not know that water and medications were supposed to be delivered via gravity . She said her last training on G-tube feedings was in nursing school about 20 years ago. She said she had been working at the facility for approximately 7 months. Interview on 2/8/23 at 4:35 p.m. with LVN A said that the facility policy for water flushes and medication administration through a plunger is via gravity. She said the protocol was not to force fluids or medications through the G-tube to prevent aspiration. Interview on 2/8/2023 at 2:25 pm. with the DON said residents who have a G-tube should have their head of bed elevated to at least 30 degrees when enteral tube was being flushed or medications was given through the pistol. She said the nurse should also be giving medications via gravity through the pistol to minimize the risk of aspiration . She said training for G-tube care and use is provided annual during competency trainings by the DON or the ADON. She said that her and the ADON will do audits with the staff including nursing to make sure the physician orders are being followed. She said a resident who has medications forced into a G-tube or improper position could cause aspiration pneumonia. Record review of the facility policy titled Enteral Tube Medication Administration effective date 9/2018 read in part .11. Elevate the head of the bed to 30-45 degrees and leave the bed in this position for at least 30 minutes after administration of medications . 15. Remove the plunger from the 60 ml syringe and connect the syringe to the clamped tubing using the appropriate port. 16. Administer each medication separately and flush the tubing between each medication. A.) Place 15ml or the prescribed amount of water in the syringe and flush the tubing using gravity flow. B.) Pour dissolved/diluted medication in the syringe and unclamp tubing, allowing medication to flow by gravity . . 455582 Page 8 of 17 455582 02/09/2023 Paradigm at Bay City 1800 13th St Bay City, TX 77414

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assured accurate administering of all drugs to meet the needs of the residents, for two (Residents #34 and #21) of 4 residents reviewed for pharmacy services, in that: medication regimen. MA A administered the wrong formulation of Aspirin to Resident #34 and 21's as ordered by the physician. The facility failed to have Resident #21's Psyllium Packet and Omeprazole available for administration. These failures could place residents at risk of not being provided medications as ordered. Findings included: Resident #34 Review of Resident #34's Face Sheet, dated 02/08/2023, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #34's diagnoses included type 2 diabetes, end stage renal disease (kidney damage and does not filter blood as well as it should), dependence on renal dialysis (removes excess fluid from the body) and hyperlipidemia (elevated cholesterol levels). ia. Review of Resident #34''s consolidated Physician Orders for February 2023 revealed an order for Aspirin EC tablet delayed release 81mg, give 1 tablet by mouth one time a day for blood thinner. Record review of Resident #34's electronic MAR (Medication Administration Record) revealed on 2/7/23 at 12:37 p.m., MA A signed off Aspirin EC tablet delayed release 81mg, give 1 tablet by mouth one time a day for blood thinner. During a medication pass observation on 2/7/23 at 9:23 a.m. with MA A. She pulled out the facility stock supply bottle of Adult Low Dose Chewable Aspirin 81mg and dispensed the medication to Resident #34. Record review of Resident #34's electronic MAR (Medication Administration Record) revealed on 2/7/23 at 12:37 p.m., MA A signed off Aspirin EC tablet delayed release 81mg, give 1 tablet by mouth one time a day for blood thinner. During an interview with MA A on 2/8/23 at 12:18 p.m. said the difference between Aspirin EC and Aspirin chewable was the medication is the same but chewable could be crushed and EC could not be crushed. MA A said the reason she gave a chewable Aspirin to Resident #34 was because Aspirin EC was unavailable, and she did not notify the assigned floor nurse of the unavailability of medication . She said she did not notify the nurse that she gave the wrong formulation of Aspirin as ordered by the physician, but she should have talked with the nurse before administering the medication to Resident #34. She said the EC and chewable Aspirin medications were the same medication but how they were prepared and given. She said she did not think there was any potential risk to the resident because of 455582 Page 9 of 17 455582 02/09/2023 Paradigm at Bay City 1800 13th St Bay City, TX 77414

F 0755 the different formula of the Aspirin. Level of Harm - Minimal harm or potential for actual harm Resident #21 Residents Affected - Few Review of Resident #21's Face Sheet, dated 02/08/2023, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #21's diagnoses included type 2 diabetes, depression, hypertension (high blood pressure) and hyperlipidemia (high cholesterol). Review of Resident #21''s consolidated Physician Orders for February 2023 revealed an order for: 1.Aspirin EC tablet delayed release 81mg, give 1 tablet by mouth one time a day for blood thinner. 2. Psyllium Packet Give 3.4grams by mouth one time a day for laxative. 3. Omeprazole 20mg Capsule delayed release give 1 capsule by mouth in the morning for GERD. Record review of Resident #21's electronic MAR (Medication Administration Record) revealed on 2/7/23 at 12:53 p.m., MA A signed off Aspirin EC tablet delayed release 81mg, give 1 tablet by mouth one time a day for blood thinner, Psyllium Packet Give 3.4 grams by mouth one time a day for laxative and Omeprazole 20mg Capsule delayed release give capsule by mouth in the morning for GERD. During a medication pass observation on 2/7/23 at 9:29 a.m. with MA A. She pulled out the facility stock supply bottle of Adult Low Dose Chewable Aspirin 81mg and dispensed the medication to Resident #21. MA A did not dispense the Psyllium packet or the Omeprazole. Record review of Resident #21's MAR and progress notes on 2/7/23 at 1:00 p.m. revealed no documentation of the physician notified of medications not given on 2/7/23 at 9:29 a.m. Record review of the MAR revealed the medications were given on 2/6/23 in the a.m. During an interview with MA A on 2/8/23 at 12:18 p.m. said the difference between Aspirin EC and Aspirin chewable was the medication is the same but chewable could be crushed and EC could not be crushed. MA A said the reason she gave a chewable Aspirin to Resident #21 because Aspirin EC unavailable and she did not notify the assigned floor nurse of the unavailability of medication. She said she did not notify the nurse that she gave the wrong formulation of Aspirin as ordered by the physician, but she should have talked with the nurse before administering the medication to Resident #21. MA A admitted that Psyllium packet and Omeprazole capsule was not given to Resident #21. She said the stock supply for Psyllium and Omeprazole was not available, but she notified the DON on 2/7/23 after the medication pass thatof t the medications were not available during the medication observation. She said the DON notified the physician was notified and Resident #21 was given his the medication was given later that day. e. Observation and on 2/9/23 at 11:30 a.m. of MA A medication cart identified stock Psyllium Packets and Omeprazole capsules available on the cart. Resident #21 also had a blister pack of Omeprazole capsule prescription, missing 3 tablets out of a 30-tablet blister pack . An interview with MA A said she did not see the blister back of Omeprazole for Resident #21 and did not know when it was reordered . Interview on 2/8/23 at 2:25 p.m. with the DON said MA A should have notified the nurse that the medications were not available immediately. The DON said the med aide also did not tell nursing that 455582 Page 10 of 17 455582 02/09/2023 Paradigm at Bay City 1800 13th St Bay City, TX 77414

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she substituted the Aspirin formula because it was not available. She said MA A did notify her after the med pass that the stock supply for Omeprazole and Psyllium Packets were not available and those medications were reordered and given later per physician's orders. The DON said if a resident only has a couple days left of medications that they should reorder the medications through the pharmacy. She said it was all nursing staff and medication aides to reorder medications that are not available. She said if medications are not given to residents or not available to give to residents could cause a possible adverse effect. Record review of facility policy Administration of Drugs revised date 6/2019 read in part . 2. If a Certified Mediation Aide is administering medications they must do so according to the Texas Administrative code . and organizations policies and procedures . 3. Medications must be administered in accordance with the written orders of the ordering/prescribing physician . 9. Unless otherwise specified by the resident's ordering/prescribing physician, routine medications should be administered as scheduled . . 455582 Page 11 of 17 455582 02/09/2023 Paradigm at Bay City 1800 13th St Bay City, TX 77414

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to store drugs and biologicals used in the facility in accordance with currently accepted professional principles and assure that medications were secure and inaccessible to unauthorized staff and residents for 1 of 1 medication room (station 3) reviewed for storage. The medication room was left unlocked and unattended in the common area by the nurse's station. This failure could place residents at risk of ingestion of medications and/or lead to possible harm or drug diversion and could place residents at risk of not receiving the therapeutic benefits of the medications. The findings included: During the medication storage room observation and interview on 02/8/23 at 9:30 a.m. LVN C pulled the medication room open without unlocking it with the keypad or using a key. The door to the room was sticking on the door frame and did not shut behind the surveyor or LVN C when entering the room. When exiting the door was stuck on the door frame. Surveyor asked if the door locked and LVN C was observed pushing the door shut and said the door shuts if it is pushed closed. She explained that the keypad was placed on the door to make sure it would lock. An observation on 2/8/23 at 9:34 a.m. MA A exited the med room and walked away without pushing the door shut and ensuring it was locked. There was no staff near the unlocked medication room and the surveyor was able to open the door. An observation and interview on 2/8/23 at 9:38 a.m. RN B returned to the nurses' station that was next to the medication storage room. She said she the door should be always locked. She said the door locks but she had to give it a good shove to close it all the way. She said she did not know who was in the medication room last, but they should have made sure that the door was locked. RN B said the door was sticking to the door frame and it just needed to be pushed shut. She did not know if the DON or administrator were aware of the door. She said she did not know if a work order had been completed related to the door sticking. An observation and interview on 2/8/23 begininng at 10:12 a.m. revealed the medication room door had a slight gap between the door and the frame and was able to be opened and no staff were visibly near the room. RN B shortly returned shortly to the nurses station and she was observed her to push close and lock the medication room. She said she did not know who was in the medication room last or how it became unlocked. She said she reported to the administrator and DON that the medication room door was sticking and not shutting all the way. Interview with the Administrator on 2/8/23 at 10:25 a.m. asking for the maintenance logs for the last month related to the medication room door was requested. The Administrator said he did not know that the medication room door was not shutting all the way. In a later interview with the Administrator, he said the maintenance man only worked as needed, but he called the maintenance man to come in shortly and fix the medication storage room door. He said it was the nursing staff who were responsible to notify the Administrator or the DON to get the issue fixed. He said the medication room door 455582 Page 12 of 17 455582 02/09/2023 Paradigm at Bay City 1800 13th St Bay City, TX 77414

F 0761 should be always locked. Level of Harm - Minimal harm or potential for actual harm Interview on 02/08/23 at 10:31 a.m. the ADON said medication carts and the medication room are to be locked at all times. She said she was unaware if there was a work order for the medication room door sticking and not shutting all the way unless pushed closed. AM LVN A revealed that she knew all the residents and she was familiar with their medications and would not mix up residents' medication. LVN A stated the three medication packages she put back in the cart belonged to two residents that were sent out to the hospital and the other resident wanted her medication right before dialysis. LVN A stated she knew what she was doing was not correct protocol. LVN A stated anyone could get into the medications and take medications. Residents Affected - Few Interview with the DON on 2/8/23 at 2:25 p.m. said the maintenance man had come and fixed the medication room door. She said the medication room door should be locked at all times and she was not notified that the door would stick and not lock. She said the nurses never reported the door as a concern. She said the risk of the medication room door not locked could be possible resident enter the room and obtain medications that they are not supposed to have access to. Record review of the facility's policy titled Storage of Medications effective date 9-2018 read in part .2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access . 455582 Page 13 of 17 455582 02/09/2023 Paradigm at Bay City 1800 13th St Bay City, TX 77414

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 reviewed for kitchen sanitation in that: The facility failed to ensure: - There were crumbs and food debris on the surfaces of the stove top and the burners, - The burners had food pieces of food stuck to them, - The griddle had food debris, grease splatters and burned on grime on the top surface, - The oven racks had an accumulation of burnt food particles and grease on them, and - There were rust stained in the clean plates holder/warmer by the steam table. - The oven baking pans and pots had burned on grime on the surface, and - Steam tablet with whitish substance on bottom. - No consistence cleaning schedule log These failures could affect residents who receive meals from the kitchen and place them at risk for foodborne illness. Findings Include: Observation of the kitchen on 02 /07/2023 beginning at7:22 AM, revealed the following: - There were crumbs and food debris on the surfaces of the stove top and the burners, - The burners had food pieces of food stuck to them, - The griddle had food debris, grease splatters and burned on grime on the top surface, - The oven racks had an accumulation of burnt food particles and grease on them, and - There was rust stained in the clean plates holder/warmer by the steam table,. - The oven baking pans, and pots had burned on grime on the surface, and - Steam tablet with whitish substance on bottom. Interview with Food Service Manager (FSM) on 02/08/23 at 12:00 PM, she said she started working for the facility about 2 years. She was asked when the oven was last cleaned. FSM said she did not have any cleaning log February 2023. FSM said the staff were supposed to clean the oven every two days 455582 Page 14 of 17 455582 02/09/2023 Paradigm at Bay City 1800 13th St Bay City, TX 77414

F 0812 Level of Harm - Minimal harm or potential for actual harm and as needed. FSM said she had staffing problem and could not do the deep cleaning. The FSM said she was responsible for training the staff on cleaning the oven, she did not have enough staff and she planning to throw away oven baking pans and pot and pans and replaced them with new pots and pans, but she has been very busy. The FSM said she knew an important reason to clean and sanitize was is to prevent the spread of pathogens to food. The FSM said most staff left with the old company. Residents Affected - Many Interview on 02/08/23 at 12:39 PM, the Administrator said, the kitchen lost some/ alot of staffs. They were hiring more people and changed with new pay raise, and she would recommend the stove to be cleaned and all kitchen staff to follow the cleaning and sanitizing schedule. Interview with the DON on 02/08/23 at 1:30 PM regarding expectation of the kitchen for cleaning and sanitation, she said the most important reason to clean and sanitize is to prevent the spread of pathogens to food. The DON said they have lost of staffing in the kitchen. Record review of current cleaning log sanitation and food safety dated 1/1/23 revealed oven was last cleaned on 01/27/2023. Record review of the Nutrition Services Policies and Procedures - Subject: Sanitation & Food Safety in Food Service dated revised 6-2019: The Nutrition/Culinary Services Director (NSD) will assume responsibility for the food safety and sanitation of the Nutrition Culinary Department. Procedures: .7. The NSD provides written cleaning instructions for each area and piece of equipment in the kitchen. The instructions specify which chemical is used for each task . . 455582 Page 15 of 17 455582 02/09/2023 Paradigm at Bay City 1800 13th St Bay City, TX 77414

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of 3 residents reviewed for infection control (Resident #95) in that Residents Affected - Few -CNA A failed to demonstrate acceptable hand sanitizing and changing of gloves when providing incontinent care for Resident #95. These failures affected one resident placing him at risk for urinary tract infections. Could affect residents and place them at risk for exposure to infections. Findings include: Resident #95 Review of Resident #1's face sheet dated 12/09/22, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of malignant neoplasm(cancer) of esophagus, malignant neoplasm of part of bronchus or lung, chronic obstructive pulmonary disease, muscle wasting and atrophy, abnormalities of gait and mobility, urinary tract infection, dysphagia (difficulty swallowing), gastro-esophageal reflux disease (gastric reflux) without esophagitis, vitamin deficiency, retention of urine and covid-19. Record review of Resident #95's admission MDS, dated [DATE], revealed a BIMS score of 15 out of 15, which indicated the resident's cognition was not impaired. Resident #95's functional status revealed she required extensive assistance with bed mobility, transfer, dressing, and personal hygiene. Resident #95 was always of incontinent of bowel and continent of bladder using indwelling catheter. Observation of Resident #95 for incontinent care on 02/08/23 at 9:20 AM performed by C.CNA A. revealed Resident #95 was lying in bed with large bowel movement. Resident # 95 have fecal matter all over his peri-area, buttock, back, beddings. C.NA A washed hands and don ( put on ) cleaned gloves, using the wet wipes cleaned the peri area with fecal matter on the gloves, C.CNA A changed gloves without washing hands or using hand sanitizer. C.CNA A changed soiled gloves with fecal matter ten times and she only used hand sanitizer twice after changing soiled gloves, CNA A then changed gloves for the eleventh time and placed a clean set of gloves on without washing or sanitizing hands. CNA A then picked up a clean brief and placed it on Resident #95. Interview on 02/08/23 at 11:35 AM with CNA A she said she had been working at the facility for approximately 1 year. CNA A said she thought she did a great job. CNA A confirmed changing gloves without washing hands or using sanitizer. CNA A said she did receive training for hand washing and she mess up. C.NA A said changing gloves without washing hands or using hand sanitizer could lead to UTI (urinary tract infection). Interview on 2/8/2023 at 3:16 PM with the DON, she said she expected staff to provide appropriate care to residents based on their needs. She said CNA A should have either washed or sanitized her hands after touching a dirty area prior to moving to a clean area when performing incontinent care. She said staff were in-serviced on infection control / hand hygiene upon hire, annually and as needed. 455582 Page 16 of 17 455582 02/09/2023 Paradigm at Bay City 1800 13th St Bay City, TX 77414

F 0880 DON said training was done in a group and not on individual staff. Level of Harm - Minimal harm or potential for actual harm Interview on 02/08/ 23 at 2:15 PM with ADON A she said she had done any in-services for hand hygiene last year. She would have to look for the skilled checks. The ADON said she would expect the CNA to change gloves and wash her hand or used hand sanitizer with each soiled gloves change to prevent infection. ADON said she was responsible for the infection control. Residents Affected - Few Interview on 02/09/23 at 9:00 AM, ADON A said she did not find the skilled checks on hand hygiene in-services she did last year . Record review of hand hygiene/ hand washing in-services done on 2/8/23, revealed: Brief outline or content . Please be sure to wash your hands or sanitize hands between glove changes. Record review of facility's policy and procedure dated 6/2019 for perineal care revealed in part: . 2. Wash hands properly before and after procedure. May use hand sanitizer in between glove changes if hands are not visibly soiled . . 455582 Page 17 of 17