Health inspection·August 3, 2023

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of CR #1's skin observation reports dated from 06/15/23 to 07/06/23 did not reveal CR #1 had any bruises on his skin. Record review of CR #1's patient information sheet from a local hospital dated 7/10/23 revealed he was admitted on [DATE] at 10:03p.m. Record review of XR chest 1 view from a local hospital dated 07/10/23 read comminuted impacted left humeral fracture. Record review of the XR Chest 1VW portable from a local hospital dated 07/11/23 revealed acute fracture left humeral neck, acute right third - fifth rib fractures, and acute left fourth - sixth rib fractures. Interview on 07/12/23 at 10:59 a.m. with the ADON said she was not aware CR#1 had bruises on his left arm until the hospital called and asked her if she was aware CR#1 had bruises, fractured left humeral neck, and multiple ribs fracture. Interview on 07/12/23 at 11:12 a.m. 11:12 a.m. with the DON said she was unaware of CR #1 had any bruises on his left arm until the hospital called and notified the ADON on 07/11/23. Interview on 07/12/23 at 11:43 a.m. with the ADON said none of the nurses or aides told her CR #1 had bruises on his left arm or was in pain. She said she would have reported it to the administrator, resident doctor, and family member, initiated the incident report, documented it on the progress report, and followed the doctor's order. She said CR #1's injury of unknown origin was not assessed, reported, or treated. She said CR #1 would have been in pain, and care was not provided for CR #1. Observation and Interview on 07/13/23 at 9:25 a.m., CR #1 was lying on his back in a hospital bed. He responded to his name. CR #1's left arm was swollen around the elbow, and he had bruised left arm, which was dark purple with some yellow discoloration, and the inner arm was purple and red and had bruised areas on his left chest. The CR #1 nurse from the hospital was in the room when the surveyor asked him what had happened to his arm, and he said he had fallen. When asked how he fell, the surveyor could not understand what he was saying. Interview on 07/13/23 at 9:32 a.m. with HHSC Interpreter (6023), CR #1 told the interpreter that he fell from his chair, and when the interpreter asked him how he fell, the interpreter said he could not understand what CR #1 was saying. Interview on 07/13/23 at 12:24 p.m. with CNA A said she worked with CR #1 in the past, and CR #1 required assistance of two-staff with mechanical lift with transfers and required two-staff assistance bed mobility and during incontinent care. She said CR #1 could not do anything for himself; the staff had to do everything for CR #1. She said CR #1 had a bruise on his left arm for about four days before he went to the hospital. Interview on 07/13/23 at 1:42 p.m. with RN I, she said she was the MDS coordinator and she heard CR #1 threw up, aspirated, had spiked a fever, was having respiratory problems, and he was sent to the hospital. She said CR #1 was very stiff and could not turn himself even if he wiggled, he could not hurt himself on the side rails. During a telephone interview on 07/13/23 at 1:59 p.m., CNA E said she noticed the bruise on CR #1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 2 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Bay City 1800 13th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some left arm on 7/10/23, which was purple, and had some green to it, and it was on the inside of his left arm too. She said the bruised area was from the elbow to just below the shoulder, and the elbow area was swollen. She said she asked CNA S who was training her about the bruises, and CNA S said the Nurse was aware of the bruises and she left it at that. Interview on 07/13/23 at 2:21 p.m. with the Administrator , she said she was unaware of bruises on CR #1's left arm. The Administrator said none of the staff mentioned it during the morning meetings. Interview on 07/13/23 at 2:41 p.m. with CNA S, she said she saw the bruises on CR #1's left arm on 07/10/23. She said CNA E (the aide she was training) asked about the bruises on CR #1's left arm from below the shoulder to the elbow; his elbow was swollen, purple, and some of the area was yellow. She told CNA E that LVN D was aware of it because that was what the Nurse that told her. She said CNA E went and told LVN D again. She said they saw the bruise around 3:30 p.m., and that was when it was reported to LVN D. Interview on 07/13/23 at 3:09 p.m., the DON said the aide should let the Nurse know of any injury, and Nurses should report it directly to her, fill out the incident report, document it in CR #1's progress note, notified the physician, and provided care per the Physician's order. She said there was no documentation showing the doctor was notified, which meant care was not provided for the bruise on his left arm before he was sent to the hospital. The DON said the CR #1 doctor came in today and wrote on his progress report that an x-ray was done on 07/10/23 at the hospital, showing signs comparable with osteoporosis due to multiple morbid conditions, contractures, and complete immobility. She also said she had reports from an old x-ray showing CR #1 may have osteoporosis or osteopenia. When asked why the resident did not have the diagnosis, she said she was not a doctor. She did not respond when asked if any intervention was implemented since she knew that CR #1 may have osteoporosis or osteopenia. During a telephone interview on 07/13/23 at 4:36 p.m. LVN D said she worked with CR #1, and he had no health issues; he ate in the dining room, was doing fine, and was in his wheelchair. She said she noticed the bruises on his right arm, and if she was not mistaken, and it was on the upper arm. She said the bruised area was from his elbow up to just below his shoulder, but she did not assess the resident to see if it was on the inside of his arm. She said she asked the resident what happened, and he did not reply. She asked CNA R, and she said it may have happened the Friday or Thursday before this Monday (07/10/23), and she said it might have been already reported to LVN W. She said she asked the ADON about the bruise on CR #1, and the ADON said she would follow up on it. She said she did not document the bruise or follow up with it or called CR #1 doctor because it did not happen on her shift. During a telephone interview on 07/13/23 at 5:23 p.m., CNA R said she reported to LVN N on 07/05/23 that CR #1 had bruises on his left arm, and he said his arm was hurting. CNA R said when LVN D (07/06/23) came to work after 7:00 a.m., she reported that CR #1 was also complaining his left arm was hurting, which was bruised, and the Nurse said to leave him in bed, and she would call the x-ray company later. She said she left work at 2:30 p.m., and the x-ray company had not come. She said the color of the bruise was a big purple bruise and some green and yellow, and she said the bruise was from the elbow close to the shoulder, and she did not touch the arm because he said it was hurting in Spanish. Record review of the facility's policy on accident and incident - investigating and reporting created 09/19/21 read in part . all accidents or incidents involving residents . occurring on our (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 3 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Bay City 1800 13th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some premises shall be investigated and reported . policy interpretation and implementation . #1 . the charge nurse and /or the department director or supervisor shall promptly initiate and document investigation of the incident . #2g. the time the injured person's attending physician was notified as well as the time the physician responded and his instructions . This was determined to be an Immediate Jeopardy (IJ) on 7/29/23 at 6:16p.m. The ADON and Administrator were notified. The ADON was provide with the IJ template on 7/29/23 at 6:16p.m. The following Plan of Removal submitted by the facility was accepted on 8/1/23 at 9:48am: Plan of Removal CR # 1 was sent to the ER on [DATE] and did not return to the facility. The Medical Director was notified by the Administrator on 7/29/23 of the Immediate Jeopardy situation. Ad Hoc QAPI was held on 7/29/23 with the Administrator, Director of Nursing, and Medical Director to review the IJ template and Plan of removal. MDS Coordinator conducted a 100% audit of ADL care plans on 7/29/23 to ensure it depicts the appropriate level of care the resident requires. Education The Director of Nursing initiated education with all staff on 7/13/23 on Reporting Changes in Resident Condition with a focus on following up on reports and notifying Administrator and DON if no interventions have been implemented, and reporting injuries of unknown origin. The Director of Nursing initiated education with all staff on 7/27/23 on Resident Rights; topics includedintroducing self when entering resident's rooms, asking permission before providing care, and the resident's right to refuse care. The Director of Nursing initiated education with Licensed Nurses and CNAs on 7/29/23 with the following topics: reviewing the resident's [NAME] prior to performing ADL care to provide the correct level of assistance. The Director of Nursing initiated education with CNAs on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA feels that the charge nurse does not address a concern that is brought to their attention, and reviewing the resident's [NAME] prior to performing ADL care to provide the correct amount of assistance. Education will be completed by 7/30/23. Any staff member who did not receive the education will not be allowed to work their next shift until completed. Educational Packets/Training will be added to facility orientation. The facility does not currently utilize agency staff. Policy Review (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 4 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Bay City 1800 13th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Change of Condition, Abuse/Neglect/Exploitation policy and procedure reviewed on 7/29/23 and required no changes. Level of Harm - Immediate jeopardy to resident health or safety Monitoring Residents Affected - Some The DON and ADON conducted grand rounds on 7/29/23 and 7/30/23 to ensure staff was providing the appropriate level of care, following the resident's [NAME], and compliant with observing resident's rights. Between 7/30/23 and 8/3/23, the surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Interviews conducted on 7/30/23 with 4 staff revealed they had recently received training on abuse, change of condition, reporting of resident injuries, contacting supervisors, resident physicians, resident responsible parties, and completing documentation. They said if they were still concerned about the resident, they would talk to the Administrator or DON. Interviews and observations conducted on 7/30/23 with 4 residents revealed they were dressed, groomed, in their rooms which were clean and a comfortable temperature. They indicated that the staff were respectful, gentle with care, and provide care in a reasonable time. They had no concerns about their medications or treatments. Interviews conducted on 7/31/23 with 3 staff revealed they had recently received training on incontinence care, abuse/neglect, mechanical lifts, customer service, informing supervisors of resident condition concerns, and documentation. Interviews and observations conducted on 7/31/23 with 3 residents revealed they were dressed, groomed, in their rooms which were clean and a comfortable temperature. They indicated that the staff were respectful, gentle with care, and provide care in a reasonable time. They had no concerns about their medications or treatments. Interview on 8/3/23 at 10:55 a.m. with the Administrator, she said she was responsible for every operation in the facility. She said she had been at the facility since 2/23. She said when she was notified of the 3 IJs, she immediately began working on the PORs. She said once she got them approved, the facility began in-servicing on 7/11/23 and again on 7/13 for all staff for education on communication, reporting change of condition, injuries of unknown origin, who to report to, the important of reporting, bruising, swelling, injuries, policy (change in condition and ANE) and nursing staff on 7/29/23. She said the DON also in-serviced nursing staff on 7/29/23 for reviewing the clinical database prior to performing ADLs so they knew what services to provide to each resident. She said on 7/29/23, all staff were trained for Resident Rights. She said it was important to train all staff to ensure residents were protected. She said staff was trained to communicate with residents, informed them of care as they provide services, and the right to be free from abuse and neglect. She said all nursing staff on mechanical lift were trained on 7/29/23. The Administrator said nursing staff that worked closely with CR#1 were included in the mechanical lift training. She said all nursing staff from all three shifts were trained on in-services and the training was conducted by the Rehab Director. She said the DON conducted the other mentioned trainings. She said the DON continue to ensure the training were effective through frequent monitoring. She said the DON conducted competency testing and return demonstration to ensure staff had understanding. The Administrator said she shared the finding with the QAPI on 7/29/23. She said she notified CR#1's Physician and the Medical Director (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 5 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Bay City 1800 13th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 directly after being notified of the IJs. Level of Harm - Immediate jeopardy to resident health or safety Interview on 8/3/23 at 11:25 am with the DON, she said she conducted 100% skin audits and there were no adverse findings on 7/13/23. She said on 7/29/23 in response to the IJ, she conducted a second 100% audit with ADON, and the MDS Nurse. She said the Medical Director was notified by the Administrator on 7/29/23 of the Immediate Jeopardy situation. She said she in-serviced all staff on Abuse and Neglect on 7/29/23. She said she also in-serviced nursing staff on reporting changes in resident condition with a focus on following up on reports of conditions to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt the charge nurse did not address a concern that was brought to their attention. She said staff were instructed to notify the Administrator and DON if no interventions had been implemented, and reporting injuries of unknown origin. Residents Affected - Some Interview on 8/3/23 at 11:44 am with the RN I, she said she was responsible for MDS assessments for all resident in the facility. She said she updated care plans and coordinated drip drive (IV hydration/nutrition therapy). She said she had been at the facility about 7 years. She said she conducted 100% audit of the ADL care plans on 7/29/23 to ensure the appropriate level of care for each resident was accurate. She said it was a great experience for her because she was able to update about 3 or 4 care plans that required re-evaluation and the appropriate updates were made. She said communication improved between therapy staff and MDS Coordinator to ensure continuum of care was not interrupted. She said she completed all resident reviews by 8/2/23. Observation and Interview on 8/3/23 at 11:50 am with Resident #1 revealed a female resident that was well-groomed and well-dressed, playing a game on her iPad. She said a staff member (she could not recall who), had asked her if anyone had been rough with her during care and if she had ever been scared when nursing staff provided care. She said no one had ever been rough with her and she was not scared. She said she knew to tell the Administrator if someone ever mistreated her. Observation and Interview on 8/3/23 at 11:55 am with Resident #2 revealed a male resident, well-groomed and well-dressed conversing with his roommate while they both watch TV. He said a staff member (ADON) asked him if anyone had been rough with his during care and if he had any ever been scared when nursing staff provided care. He said no one had ever been rough with him and he was not scared. He said she knew to tell the Administrator if someone ever mistreated him. Observation and Interview on 8/3/23 at 12:05 pm with Resident #3 revealed a male resident, well-groomed and well-dressed having a conversation with his roommate. He said a staff member (ADON) asked him if anyone had been rough with him during care and if he had ever been scared when nursing staff provided care. He said no one had ever been rough with him and he was not scared. He said he knew to tell the Administrator if someone ever mistreated him. Observation and Interview on 8/3/23 at 12:15 pm with Resident #4 revealed a male resident, well-groomed and dressed in shorts and a t-shirt. He said a staff member (ADON) asked him if anyone had been rough with him during care and if he had ever been scared when nursing staff provided care. He said no one had ever been rough with him and he was not scared. He said he did not speak with the Administrator because she would tell him that she would return to speak with him but never would return. He said the Business Service Manager made rounds every morning to see how residents were doing. He said he would tell the Business Service Manager if anyone mistreated him. Observation and Interview on 8/3/23 at 12:20 pm with Resident #5 revealed a male resident, well-groomed and well-dressed watching TV. He said a staff member (ADON) asked him if anyone had been rough (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 6 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Bay City 1800 13th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some with his during care and if he had ever been scared when nursing staff provided care. He said no one had ever been rough with him and he was not scared. He said he knew to tell the Administrator if someone ever mistreated him. Interview on 8/3/23 at 1:11 pm with Med Tech A, she said she worked the morning shift (6am to 2pm). She said the DON trained all nursing staff on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt that the charge nurse did not address a concern that was brought to their attention, and reviewing the resident's clinical database prior to performing ADL care so they knew to provide residents with the appropriate level of care/services. She said she was also trained on the use and transfer with the Hoyer lift. Interview on 8/3/23 at 1:11 pm with LVN C, she said she worked the morning shift (6am to 2pm). She said the DON trained all nursing staff on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt that the charge nurse did not address a concern that was brought to their attention, and reviewing the resident's clinical database prior to performing ADL care so they knew to provide residents with the appropriate level of care/services. She said she was also trained on the use and transfer with the Hoyer lift. Interview on 8/3/23 at 1:11 pm with Restorative Aide A, she said she worked the morning shift (6am to 2pm). She said the DON trained all nursing staff on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt that the charge nurse did not address a concern that was brought to their attention, and reviewing the resident's clinical database prior to performing ADL care so they knew to provide residents with the appropriate level of care/services. She said she was also trained on the use and transfer with the mechanical lift. Interview on 8/3/23 at 1:11 pm with CNA B, she said she worked the morning shift (6 a.m. to 2 p.m.). She said she provided care to CR#1. She said he required 2 persons assist for transfers with a Hoyer lift. She said he had a high level of care because he was dependent on assistance for all ADL's. She said she was trained due to the failure of reporting a change in condition for CR#1, so she was re-trained. She said the DON trained all nursing staff on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt that the charge nurse did not address a concern that was brought to their attention, and reviewing the resident's clinical database prior to performing ADL care so they knew to provide residents with the appropriate level of care/services. She said she was also trained on the use and transfer with the mechanical lift. The Administrator was informed the Immediate Jeopardy was removed on 8/3/23 at 1:50pm. The facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 7 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Bay City 1800 13th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents had the right to be free from neglect for one (CR #1) of four residents reviewed for neglect. Residents Affected - Some -The facility staff (LVN N and LVN D) failed to assess and treat CR #1, who was dependent on staff for all care, when he was discovered with injury of unknown origin that included a bruise on his arm. CR #1 was admitted to the hospital on [DATE] with a left humeral fracture and acute rib fractures. -facility failed to ensure CNA E did not provide incontinent care to CR #1 by herself when care required two staff. An IJ was identified on 7/29/23. The IJ template was provided to the facility on 7/29/23 at 6:16 p.m. While the IJ was removed on 8/3/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm because all staff had not been trained on reporting and assessing changes of condition. These failures could place residents at risk of neglect from facility staff. Findings include: Record review of CR #1's admission face sheet revealed an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included dementia ( loss of memory, language, problem -solving and other thinking ability), quadriplegia (paralysis below the neck that affect all of a person's limbs), sepsis (the body's extreme response to an infection), and acute respiratory failure with hypoxia (a serious condition that makes it difficult to breath on your own and a condition where you do not have enough oxygen in the tissues in the body). Record review of CR #1's quarterly MDS assessment, dated 05/12/23, revealed the BIMS score was 00, which indicated severely impaired cognition. Further review of the MDS revealed he was always incontinent of bowel and bladder and required extensive assistance with two staff assist with bed mobility, transfers and toileting. Record review of CR #1's care plan initiated on 08/26/16 and revised on 10/04/22 revealed CR #1 required total assist by 2 staff for bed mobility and required total assistance of 1 staff for toileting. Record review of CR # 1's medication review report for July 2023 did not reflect any order for x - ray. Record review of CR #1's skin observation report dated from 06/15/23 to 07/06/23 did not reveal CR #1 had any bruises on his skin. Record review of CR #1's patient information sheet from a local hospital dated 7/10/23 revealed he was admitted on [DATE] at 10:03p.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 8 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Bay City 1800 13th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of CR #1's XR chest 1 view from a local hospital dated 07/10/23 read comminuted impacted left humeral fracture. Record review of CR # 1's XR Chest 1VW portable from a local hospital dated 07/11/23 revealed acute fracture left humeral neck, acute right third - fifth rib fractures, and acute left fourth - sixth rib fractures. Interview on 07/12/23 at 10:59 a.m., the ADON said she was not aware CR#1 had bruises on his left arm until the hospital called on 07/11/23 and asked her if she was aware CR#1 had bruises, fractured left humeral neck, and multiple ribs fracture. Interview on 07/12/23 at 11:12 a.m., the DON said she was unaware CR #1 had any bruises on his left arm until the hospital called and notified the ADON on 07/11/23. Interview on 07/12/23 at 11:43 a.m., the ADON said none of the nurses or aides told her CR #1 had bruises on his left arm or was in pain. She said she would have reported it to the administrator, resident doctor, and family member, initiated the incident report, documented it on the progress report, and followed the doctor's order. She said CR #1's injury of unknown origin was not assessed, reported, or treated. She said CR #1 would have been in pain, and care was not provided for CR #1. She said the floor nurse does weekly skin assessment and document if there were any issues with skin and report to her and the DON. Observation and Interview on 07/13/23 at 9:25 a.m., CR #1 was lying on his back in a hospital bed. He responded to his name. CR #1's left arm was swollen around the elbow, and he had bruise on his left arm, which was dark purple with some yellow discoloration. The inner arm was purple and red and had bruised areas on his left chest. When the surveyor asked him what had happened to his arm, he said he had fallen. When asked how he fell, the surveyor could not understand what he was saying. Surveyor conducted an interview with CR #1 using HHSC interpreter (6023) on 07/13/23 at 9:32 a.m. CR #1 told the interpreter in Spanish that he fell from his chair, and when the interpreter asked him how he fell, the interpreter said he could not understand what CR #1 was saying. Interview on 07/13/23 at 12:24 p.m., CNA A said she worked with CR #1 in the past. She said CR #1 required the assistance of two staff with a mechanical lift for transfers, and required the assistance of two staff for bed mobility and incontinent care. She said CR #1 could not do anything for himself; the staff had to do everything for him. She said CR #1 had a bruise on his left arm for about four days before he went to the hospital. She said she did not report the bruise on CR#1's arm because she was told it had been reported to LVN D. During a telephone interview on 07/13/23 at 1:07 p.m., LVN W said CNA E called and told her CR #1 was having a breathing problem on 07/10/23 at about 8:00p.m. When she saw CR #1, he was breathing shallow, and she checked his O2 sat, it was 85%, and she called 911 to take the resident to the hospital. She said the aide had just finished changing the resident by herself, but the resident required two-person assistance, and she did not tell her if the resident fell or hit any part of his body on the bed. She said she did not assess the resident's skin because the aide had cleaned him up, and he was good to go, and she sent him out and did not notice any bruise on his arm. She said she was concerned about his breathing, which was why she did not assess the resident. She said the resident does not speak too well, and you cannot really understand him, but he did not say anything about being in pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 9 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Bay City 1800 13th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Interview on 07/13/23 at 1:42 p.m., RN I said CR #1 was very stiff and could not turn himself even if he wiggled himself; he could not hurt himself on the side rails. She said the resident needed two people to assist with incontinent care in bed and for transfers. She said if one aide provided the care, she did not follow CR #1's plan of care which could cause an injury to CR #1. She said CR #1 went to the hospital on 7/10/23 because he threw up, aspirated, had spiked a fever, and was having respiratory problems. She said the administrator was the abuse coordinator and abuse/neglect should be reported immediately. She said the administrator and the DON does in service on abuse/neglect and she had in-service about two weeks ago. During a telephone interview on 07/13/23 at 1:59 p.m., CNA E said she went into CR #1's room, and he was not looking right (difficulty breathing) on 07/10/23 about 8:00 p.m. She called LVN W, and the nurse checked his oxygen, which was 85%. She said she provided incontinent care for CR #1 by herself because that was her first day of orientation on the floor, and she did not know he required two-person assistance. She said she transferred the resident to bed with CNA S earlier, around 3:30 p.m., because the resident vomited. CNA E said she noticed the bruise on CR #1 left arm, which was purple, and had some green to it, and it was on the inside of his left arm too. She said the bruised area was from the elbow to just below the shoulder, and the elbow area was swollen. She stated she asked CNA S who was training her about the bruises, and CNA S said the nurse was aware of the bruise and she left it at that. Interview on 07/13/23 at 2:21 p.m., the Administrator said she was unaware of bruises on CR #1's left arm. The administrator said none of the staff mentioned it during the morning meetings. Interview on 07/13/23 at 2:41 p.m. CNA S said she saw the bruise on CR #1's left arm on 07/10/23. She said CNA E (the aide she was training) asked about the bruise on CR #1's left arm from below the shoulder to the elbow; his elbow was swollen, purple, and some of the area was yellow. She told CNA E that LVN D was aware of it because that was what the person that told her said. She said CNA E went and told LVN D again. She said they saw the bruise around 3:30 p.m., and that was when it was reported to LVN D. CNA S said CNA E went and changed CR #1 by herself, but CR#1 needed two staff assistance. CNA S said she forgot to tell CNA E that CR #1 needed two-person assistance for incontinent care, and CNA E did not tell her she was going to provide incontinent for CR #1. She said CR #1 could get hurt if one person provided care. Interview on 07/13/23 at 3:05 p.m., the Administrator said she was the abuse coordinator for the facility, and her expectation was for the staff to notify her immediately if there was any incident. Still, they had to follow the chain of command. The Administrator said, she and the DON conducts in service on abuse/neglect and the staff were told to report to their immediate supervisor who would then report to her. She said if a resident had an injury and the staff did not report it to her, it was a deficient practice because she would only report if she were made aware of the incident. Interview on 07/13/23 at 3:09 p.m., the DON said the aide should let the nurse know of any injury, and nurses should report it directly to her, fill out the incident report, and document it in CR #1's progress note and notify the physician and provide care per his order. She said there was no documentation showing the doctor was notified, which meant care was not provided for the bruise on his left arm before he was sent to the hospital. The DON said the CR #1's doctor came in today and wrote on his progress report that an x-ray was done on 07/10/23 at the hospital, showing signs comparable with osteoporosis (decrease in the amount and thickness of bone tissue) due to multiple morbid conditions, contractures, and complete immobility. She also said she had reports from an old x-ray showing CR #1 may have osteoporosis or osteopenia (a loss of bone density that weakens the bones). When (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 10 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Bay City 1800 13th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some asked why the resident did not have the diagnosis, she said she was not a doctor. She did not respond when asked if any intervention was implemented since she knew that CR #1 may have osteoporosis or osteopenia. The DON said CR #1 needed two-person assistance with transfer and bed mobility, and two staff should have provided the incontinent care if it was care planned for two staff. During a telephone interview on 07/13/23 at 4:36 p.m. LVN D said she worked with CR #1, and he had no health issues; She said she noticed the bruises on his right arm, and if she was not mistaken, it was on the upper arm. She said the bruised area was from his elbow up to just below his shoulder, but she did not assess the resident to see if it was on the inside of his arm. She said she asked the resident what happened, and he did not reply. She asked CNA R, and she said it may have happened the Friday or Thursday (07/06/23 or 07/07/23) before this Monday (07/10/23), and she said it might have been reported to LVN W. She said she asked the ADON about the bruise on CR #1, and the ADON said she would follow up on it. She said she did not document the bruise or follow up with it or call CR #1's doctor because it did not happen on her shift. During a telephone interview on 07/13/23 at 5:23 p.m., CNA R said she reported to LVN N, the night nurse, on 07/05/23 that CR #1 had bruises on his left arm, and he stated his arm was hurting. CNA R said when her morning nurse LVN D (07/06/23) came to work after 7:00 a.m., she reported that CR #1 was also complaining his left arm which was bruised, was hurting, , and she said to leave him in bed, and she would call the x-ray company later. She said she left work at 2:30 p.m., and the x-ray company had not come. She said CR #1 said the bald white man pulled his arm hard to put his shirt on, which was painful. She said the color of the bruise was a big purple bruise and some green and yellow. She said the bruise was from the elbow close to the shoulder. She said she did not touch the arm because he said it was hurting in Spanish. She also said CR #1 said the aide with long nails and a big butt was rough when she transferred him to the bed last night (07/05/23), and she did not understand clearly if he meant she gave him a bear hug when she transferred him to bed. Interview on 07/13/23 at 5:50 p.m., the Administrator said she could not believe she was in the building on 07/04/23 and an incident (CR #1 bruise) happened, and she was not told about it. She said she could not believe the staff would not own up if they did something wrong (CR #1 bruise) instead, they would be calling other staff names. She said since the incident was not reported, CR #1 was not treated for the injury, and she did not report the incident until 07/11/23 after the hospital called and notified the facility about the injury. Record review of the facility's policy on accident and incident - investigating and reporting created 09/19/21 read in part . all accidents or incidents involving residents . occurring on our premises shall be investigated and reported . policy interpretation and implementation . #1 . the charge nurse and /or the department director or supervisor shall promptly initiate and document investigation of the incident . #2g. the time the injured person's attending physician was notified as well as the time the physician responded and his instructions . Record review of the facility policy on abuse/neglect revised 6/2019 read in part . it is the policy of this facility to provide professional care and services in an environment that is free from any type of . Neglect . definition of neglect . failure to react to a situation which may be harmful . neglect may be or may not be intentional . signs and symptoms of suspected abuse/neglect . #1 . prolonged interval between trauma/illness and seeking medical attention . This was determined to be an Immediate Jeopardy (IJ) on 7/29/23 at 6:16p.m. The ADON and Administrator were notified. The ADON was provide with the IJ template on 7/29/23 at 6:16p.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 11 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Bay City 1800 13th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 The following Plan of Removal submitted by the facility was accepted on 8/1/23 at 9:48am: Level of Harm - Immediate jeopardy to resident health or safety Facility Plan of Removal Residents Affected - Some The Facility Self-Reported CR #1s fractures on 7/11/23 with subsequent investigation. The investigation was inconclusive with discrepancies in the origin and location of resident fractures. CR # 1 was sent to the ER on [DATE] and did not return to the facility. The Director of Nursing conducted 1:1 training with staff members who were identified as failing to report changes in condition in CR #1 and were completed by 7/21/23. The Director of Nursing conducted a sample of resident questionnaires screening for abuse or neglect on 7/11/23 with no adverse findings. The Medical Director was notified by the Administrator on 7/29/23 of the Immediate Jeopardy situation. Ad Hoc QAPI was held on 7/14/23 with the Administrator, DON, and Medical Director with the following topics: Incident Reporting Process, Changes of Condition, Reporting Incidents and Accidents appropriately. Ad Hoc QAPI was held on 7/29/23 with the Administrator, Director of Nursing, and Medical Director to review the IJ template and Plan of removal. A 100% skin audit was completed 7/13/23 by the MDS Nurse and Charge Nurse. No adverse findings were noted. A 100% skin audit was repeated by the DON, ADON, and MDS Nurse on 7/29/23 in response to the IJ. Audits were conducted to ensure there was no bruising or injuries of unknown origin. No adverse findings were noted. DON reviewed Incidents and Accidents x 30 days to ensure any Injuries of Unknown Origin were communicated with the Physician, orders obtained, and Reported to HHSC as necessary. No adverse findings were noted. Education The Director of Nursing initiated education on 7/11/23 on Abuse and Neglect with all facility staff. The Director of Nursing initiated education with all staff on 7/13/23 on Reporting Changes in Resident Condition with a focus on following up on reports and notifying Administrator and DON if no interventions have been implemented, and reporting injuries of unknown origin. The Director of Nursing initiated education with Licensed Nurses on 7/29/23 with the following topics: Reporting changes of condition to include any injuries of unknown origin/bruising/swelling to the Physician, Changes of Condition Policy and Procedure, and Abuse/Neglect/Exploitation. The Director of Nursing initiated education with CNAs on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA feels that the charge nurse does not address a concern that is brought to their attention. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 12 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Bay City 1800 13th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Education will be completed by 7/30/23. Any staff member who did not receive the education will not be allowed to work their next shift until completed. Educational Packets/Training will be added to facility orientation. The facility does not currently utilize agency staff. Policy Review Change of Condition, Abuse/Neglect/Exploitation policy and procedure reviewed on 7/29/23 and required no changes. Between 7/30/23 and 8/3/23, the surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Interviews conducted on 7/30/23 with 4 staff revealed they had recently received training on abuse, change of condition, reporting of resident injuries, contacting supervisors, resident physicians, resident responsible parties, and completing documentation. They said if they were still concerned about the resident, they would talk to the Administrator or DON. Interviews and observations conducted on 7/30/23 with 4 residents revealed they were dressed, groomed, in their rooms which were clean and a comfortable temperature. They indicated that the staff were respectful, gentle with care, and provide care in a reasonable time. They had no concerns about their medications or treatments. Interviews conducted on 7/31/23 with 3 staff revealed they had recently received training on incontinence care, abuse/neglect, mechanical lifts, customer service, informing supervisors of resident condition concerns, and documentation. Interviews and observations conducted on 7/31/23 with 3 residents revealed they were dressed, groomed, in their rooms which were clean and a comfortable temperature. They indicated that the staff were respectful, gentle with care, and provide care in a reasonable time. They had no concerns about their medications or treatments. Interview on 8/3/23 at 10:55 a.m. with the Administrator, she said she was responsible for every operation in the facility. She said she had been at the facility since 2/23. She said when she was notified of the immediate jeopardies, she immediately began working on the PORs. She said once she got them approved, the facility began in-servicing on 7/11/23 and again on 7/13 for all staff for education on communication, reporting change of condition, injuries of unknown origin, who to report to, the important of reporting, bruising, swelling, injuries, policy (change in condition and ANE) and nursing staff on 7/29/23. She said the DON also in-serviced nursing staff on 7/29/23 for reviewing the clinical database prior to performing ADLs so they knew what services to provide to each resident. She said on 7/29/23, all staff were trained for Resident Rights. She said it was important to train all staff to ensure residents were protected. She said staff was trained to communicate with residents, informed them of care as they provide services, and the right to be free from abuse and neglect. She said all nursing staff on mechanical lift were trained on 7/29/23. The Administrator said nursing staff that worked closely with CR#1 were included in the mechanical lift training. She said all nursing staff from all three shifts were trained on in-services and the training was conducted by the Rehab Director. She said the DON conducted the other mentioned trainings. She said the DON continue to ensure the training were effective through frequent monitoring. She said the DON conducted competency testing and return demonstration to ensure staff had understanding. The Administrator said she shared the finding with the QAPI on 7/29/23. She said she notified CR#1's Physician and the Medical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 13 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Bay City 1800 13th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Director directly after being notified of the IJs. Level of Harm - Immediate jeopardy to resident health or safety Interview on 8/3/23 at 11:25 am with the DON, she said she conducted 100% skin audits and there were no adverse findings on 7/13/23. She said on 7/29/23 in response to the IJ, she conducted a second 100% audit with ADON, and the MDS Nurse. She said the Medical Director was notified by the Administrator on 7/29/23 of the Immediate Jeopardy situation. She said she in-serviced all staff on Abuse and Neglect on 7/29/23. She said she also in-serviced nursing staff on reporting changes in resident condition with a focus on following up on reports of conditions to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt the charge nurse did not address a concern that was brought to their attention. She said staff were instructed to notify the Administrator and DON if no interventions had been implemented, and reporting injuries of unknown origin. Residents Affected - Some Interview on 8/3/23 at 11:44 am with the RN I, she said she was responsible for MDS assessments for all resident in the facility. She said she updated care plans and coordinated drip drive (IV hydration/nutrition therapy). She said she had been at the facility about 7 years. She said she conducted 100% audit of the ADL care plans on 7/29/23 to ensure the appropriate level of care for each resident was accurate. She said it was a great experience for her because she was able to update about 3 or 4 care plans that required re-evaluation and the appropriate updates were made. She said communication improved between therapy staff and MDS Coordinator to ensure continuum of care was not interrupted. She said she completed all resident reviews by 8/2/23. Observation and Interview on 8/3/23 at 11:50 am with Resident #1 revealed a female resident that was well-groomed and well-dressed, playing a game on her iPad. She said a staff member (she could not recall who), had asked her if anyone had been rough with her during care and if she had ever been scared when nursing staff provided care. She said no one had ever been rough with her and she was not scared. She said she knew to tell the Administrator if someone ever mistreated her. Observation and Interview on 8/3/23 at 11:55 am with Resident #2 revealed a male resident, well-groomed and well-dressed conversing with his roommate while they both watch TV. He said a staff member (ADON) asked him if anyone had been rough with his during care and if he had any ever been scared when nursing staff provided care. He said no one had ever been rough with him and he was not scared. He said she knew to tell the Administrator if someone ever mistreated him. Observation and Interview on 8/3/23 at 12:05 pm with Resident #3 revealed a male resident, well-groomed and well-dressed having a conversation with his roommate. He said a staff member (ADON) asked him if anyone had been rough with him during care and if he had ever been scared when nursing staff provided care. He said no one had ever been rough with him and he was not scared. He said he knew to tell the Administrator if someone ever mistreated him. Observation and Interview on 8/3/23 at 12:15 pm with Resident #4 revealed a male resident, well-groomed and dressed in shorts and a t-shirt. He said a staff member (ADON) asked him if anyone had been rough with him during care and if he had ever been scared when nursing staff provided care. He said no one had ever been rough with him and he was not scared. He said he did not speak with the Administrator because she would tell him that she would return to speak with him but never would return. He said the Business Service Manager made rounds every morning to see how residents were doing. He said he would tell the Business Service Manager if anyone mistreated him. Observation and Interview on 8/3/23 at 12:20 pm with Resident #5 revealed a male resident, well-groomed and well-dressed watching TV. He said a staff member (ADON) asked him if anyone had been rough (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 14 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Bay City 1800 13th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some with his during care and if he had ever been scared when nursing staff provided care. He said no one had ever been rough with him and he was not scared. He said he knew to tell the Administrator if someone ever mistreated him. Interview on 8/3/23 at 1:11 pm with Med Tech A, she said she worked the morning shift (6am to 2pm). She said the DON trained all nursing staff on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt that the charge nurse did not address a concern that was brought to their attention, and reviewing the resident's clinical database prior to performing ADL care so they knew to provide residents with the appropriate level of care/services. She said she was also trained on the use and transfer with the Hoyer lift. Interview on 8/3/23 at 1:11 pm with LVN C, she said she worked the morning shift (6am to 2pm). She said the DON trained all nursing staff on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt that the charge nurse did not address a concern that was brought to their attention, and reviewing the resident's clinical database prior to performing ADL care so they knew to provide residents with the appropriate level of care/services. She said she was also trained on the use and transfer with the Hoyer lift. Interview on 8/3/23 at 1:11 pm with Restorative Aide A, she said she worked the morning shift (6am to 2pm). She said the DON trained all nursing staff on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt that the charge nurse did not address a concern that was brought to their attention, and reviewing the resident's clinical database prior to performing ADL care so they knew to provide residents with the appropriate level of care/services. She said she was also trained on the use and transfer with the mechanical lift. Interview on 8/3/23 at 1:11 pm with CNA B, she said she worked the morning shift (6 a.m. to 2 p.m.). She said she provided care to CR#1. She said he required 2 persons assist for transfers with a Hoyer lift. She said he had a high level of care because he was dependent on assistance for all ADL's. She said she was trained due to the failure of reporting a change in condition for CR#1, so she was re-trained. She said the DON trained all nursing staff on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt that the charge nurse did not address a concern that was brought to their attention, and reviewing the resident's clinical database prior to performing ADL care so they knew to provide residents with the appropriate level of care/services. She said she was also trained on the use and transfer with the mechanical lift. The Administrator was informed the Immediate Jeopardy was removed on 8/3/23 at 1:50pm. The facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 15 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Bay City 1800 13th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed, based on the comprehensive assessment, to ensure residents received the care and services in accordance with professional standards of practice for one of four residents (CR #1) reviewed for quality of care. Residents Affected - Some -The facility failed to ensure nursing staff assessed and treated CR #1 when LVN D identified a bruise on his left arm. CR #1 was bed-bound and depended on staff for care when he sent to the hospital for issues unrelated to the bruise, revealing CR#1 sustained a left humeral fracture and multiple acute bilateral rib fractures. An IJ was identified on 7/29/23. The IJ template was provided to the facility on 7/29/23 at 6:16 p.m. While the IJ was removed on 8/3/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm because all staff had not been trained on reporting and assessing for changes of condition. This failure placed residents at risk of a delay in care and worsening of their medical condition. Findings include: Record review of CR #1's admission face sheet revealed an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included dementia( loss of memory, language, problem -solving and other thinking ability), quadriplegia(paralysis below the neck that affect all of a person's limbs), sepsis(the body's extreme response to an infection), and acute respiratory failure with hypoxia(a serious condition that makes it difficult to breath on your own and a condition where you do not have enough oxygen in the tissues in the body). Record review of CR #1's quarterly MDS assessment, dated 05/12/23, revealed the BIMS score was 00, which indicated severely impaired cognition. Further review of the MDS revealed he was always incontinent of bowel and bladder and required extensive assistance with two staff assist with bed mobility, transfers and toileting. Record review of CR #1's care plan initiated on 08/26/16 and revised on 10/04/22 revealed CR #1 required total assist by 2 staff for bed mobility and required total assistance of 1 staff for toileting. Record review of CR # 1's medication review report for July 2023 did not reflect any order for a x -ray. Record review of CR #1's skin observation reports dated from 06/15/23 to 07/06/23 did not reveal CR #1 had any bruises on his skin. Record review of CR #1's patient information sheet from a local hospital dated 7/10/23 revealed he was admitted on [DATE] at 10:03p.m. Record review of XR chest 1 view from a local hospital dated 07/10/23 read comminuted impacted left humeral fracture. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 16 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Bay City 1800 13th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Record review of the XR Chest 1VW portable from a local hospital dated 07/11/23 revealed acute fracture left humeral neck, acute right third - fifth rib fractures, and acute left fourth - sixth rib fractures. Interview on 07/12/23 at 10:59 a.m. with the ADON said she was not aware CR#1 had bruises on his left arm until the hospital called and asked her if she was aware CR#1 had bruises, fractured left humeral neck, and multiple ribs fracture. Residents Affected - Some Interview on 07/12/23 at 11:12 a.m. 11:12 a.m. with the DON said she was unaware of CR #1 had any bruises on his left arm until the hospital called and notified the ADON on 07/11/23. Interview on 07/12/23 at 11:43 a.m. with the ADON said none of the nurses or aides told her CR #1 had bruises on his left arm or was in pain. She said she would have reported it to the administrator, resident doctor, and family member, initiated the incident report, documented it on the progress report, and followed the doctor's order. She said CR #1's injury of unknown origin was not assessed, reported, or treated. She said CR #1 would have been in pain, and care was not provided for CR #1. Observation and Interview on 07/13/23 at 9:25 a.m., CR #1 was lying on his back in a hospital bed. He responded to his name. CR #1's left arm was swollen around the elbow, and he had bruised left arm, which was dark purple with some yellow discoloration, and the inner arm was purple and red and had bruised areas on his left chest. The CR #1 nurse from the hospital was in the room when the surveyor asked him what had happened to his arm, and he said he had fallen. When asked how he fell, the surveyor could not understand what he was saying. Interview on 07/13/23 at 9:32 a.m. with HHSC Interpreter (6023), CR #1 told the interpreter that he fell from his chair, and when the interpreter asked him how he fell, the interpreter said he could not understand what CR #1 was saying. Interview on 07/13/23 at 12:24 p.m. with CNA A said she worked with CR #1 in the past, and CR #1 required assistance of two-staff with mechanical lift with transfers and required two-staff assistance bed mobility and during incontinent care. She said CR #1 could not do anything for himself; the staff had to do everything for CR #1. She said CR #1 had a bruise on his left arm for about four days before he went to the hospital. During a telephone interview on 07/13/23 at 1:07 p.m. with LVN W said CNA E called and told her CR #1 was having a breathing problem, and when she saw CR #1, he was breathing shallow, and she checked his O2 sat, it was 85%, and she called 911 to take the resident to the hospital. She said CNA E had just finished changing the resident by herself, and she did not tell her if the resident fell or hit any part of his body on the bed. She said she did not do any skin assessment on the resident because the CNA E had cleaned him up, and he was good to go to the hospital. She sent him out and did not notice any bruises on his arm. She said she was concerned about his breathing, which was why she did not assess the resident. She said the resident does not speak too well, you really cannot understand him, but he did not say anything about being in pain. Interview on 07/13/23 at 1:42 p.m. with RN I, she said she was the MDS coordinator and she heard CR #1 threw up, aspirated, had spiked a fever, was having respiratory problems, and he was sent to the hospital. She said CR #1 was very stiff and could not turn himself even if he wiggled, he could not hurt himself on the side rails. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 17 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Bay City 1800 13th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some During a telephone interview on 07/13/23 at 1:59 p.m., CNA E revealed she went into CR #1's room, and he was not looking right. She called LVN W, and the nurse checked his oxygen, which was 85%. She said she provided incontinent care for CR #1 by herself because that was her first day of orientation on the floor, and she did not know he was two persons assist. She said she transferred the resident to bed with CNA S earlier, around 3:30 p.m., because the resident vomited. CNA E said she noticed the bruise on CR #1 left arm, which was purple, and had some green to it, and it was on the inside of his left arm too. She said the bruised area was from the elbow to just below the shoulder, and the elbow area was swollen. She said she asked CNA S who was training her about the bruises, and CNA S said the Nurse was aware of the bruises and she left it at that. Interview on 07/13/23 at 2:21 p.m. with the Administrator , she said she was unaware of bruises on CR #1's left arm. The Administrator said none of the staff mentioned it during the morning meetings. Interview on 07/13/23 at 2:41 p.m. with CNA S, she said she saw the bruises on CR #1's left arm on 07/10/23. She said CNA E (the aide she was training) asked about the bruises on CR #1's left arm from below the shoulder to the elbow; his elbow was swollen, purple, and some of the area was yellow. She told CNA E that LVN D was aware of it because that was what the Nurse that told her. She said CNA E went and told LVN D again. She said they saw the bruise around 3:30 p.m., and that was when it was reported to LVN D. CNA S said CNA E went and changed CR #1 by herself, but CR #1 needed two staff assistance. Interview on 07/13/23 at 3:05 p.m. with the Administrator, she said she was the Abuse Coordinator for the facility, and her expectation was for the staff to notify her immediately if there was any incident. She continued - still, they have to follow the chain of command. She said if a resident had an injury and the staff did not report it to her, it was a deficient practice because she would only report if she were made aware of the incident. Interview on 07/13/23 at 3:09 p.m., the DON said the aide should let the Nurse know of any injury, and Nurses should report it directly to her, fill out the incident report, document it in CR #1's progress note, notified the physician, and provided care per the Physician's order. She said there was no documentation showing the doctor was notified, which meant care was not provided for the bruise on his left arm before he was sent to the hospital. The DON said the CR #1 doctor came in today and wrote on his progress report that an x-ray was done on 07/10/23 at the hospital, showing signs comparable with osteoporosis due to multiple morbid conditions, contractures, and complete immobility. She also said she had reports from an old x-ray showing CR #1 may have osteoporosis or osteopenia. When asked why the resident did not have the diagnosis, she said she was not a doctor. She did not respond when asked if any intervention was implemented since she knew that CR #1 may have osteoporosis or osteopenia. The DON said CR #1 needed two-person assistance with transfer and bed mobility, and two staff should have provided the incontinent care if it was care planned for two staff. During a telephone interview on 07/13/23 at 4:36 p.m. LVN D said she worked with CR #1, and he had no health issues; he ate in the dining room, was doing fine, and was in his wheelchair. She said she noticed the bruises on his right arm, and if she was not mistaken, and it was on the upper arm. She said the bruised area was from his elbow up to just below his shoulder, but she did not assess the resident to see if it was on the inside of his arm. She said she asked the resident what happened, and he did not reply. She asked CNA R, and she said it may have happened the Friday or Thursday before this Monday (07/10/23), and she said it might have been already reported to LVN W. She said she asked the ADON about the bruise on CR #1, and the ADON said she would follow up on it. She said she did not document the bruise or follow up with it or called CR #1 doctor because it did not happen on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 18 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Bay City 1800 13th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 her shift. Level of Harm - Immediate jeopardy to resident health or safety During a telephone interview on 07/13/23 at 5:23 p.m., CNA R said she reported to LVN N on 07/05/23 that CR #1 had bruises on his left arm, and he said his arm was hurting. CNA R said when LVN D (07/06/23) came to work after 7:00 a.m., she reported that CR #1 was also complaining his left arm was hurting, which was bruised, and the Nurse said to leave him in bed, and she would call the x-ray company later. She said she left work at 2:30 p.m., and the x-ray company had not come. She said CR #1 told her, the bald white man pulled his arm hard to put his shirt on, which was painful. She said the color of the bruise was a big purple bruise and some green and yellow, and she said the bruise was from the elbow close to the shoulder, and she did not touch the arm because he said it was hurting in Spanish. She also said CR #1 said the aide with long nails and a big butt was rough when she put him in bed last night (07/05/23), and she did not understand clearly if he meant she gave him a bear hug when she transferred him to bed. Residents Affected - Some Interview on 07/13/23 at 5:50 p.m. with the Administrator who said she could not believe she was in the building on 07/04/23 and had an incident and was not told about it. Instead, they would go and tell the people in the community. She also said she could not believe the staff would not own up if they did something wrong instead, they would be calling other staff names. Record review of the facility's policy on accident and incident - investigating and reporting created 09/19/21 read in part . all accidents or incidents involving residents . occurring on our premises shall be investigated and reported . policy interpretation and implementation . #1 . the charge nurse and /or the department director or supervisor shall promptly initiate and document investigation of the incident . #2g. the time the injured person's attending physician was notified as well as the time the physician responded and his instructions . This was determined to be an Immediate Jeopardy (IJ) on 7/29/23 at 6:16p.m. The ADON and Administrator were notified. The ADON was provide with the IJ template on 7/29/23 at 6:16p.m. The following Plan of Removal submitted by the facility was accepted on 8/1/23 at 9:48am: Plan of Removal CR # 1 was sent to the ER on [DATE] and did not return to the facility. The Medical Director was notified by the Administrator on 7/29/23 of the Immediate Jeopardy situation. Ad Hoc QAPI was held on 7/29/23 with the Administrator, Director of Nursing, and Medical Director to review the IJ template and Plan of removal. MDS Coordinator conducted a 100% audit of ADL care plans on 7/29/23 to ensure it depicts the appropriate level of care the resident requires. Education The Director of Nursing initiated education with all staff on 7/13/23 on Reporting Changes in Resident Condition with a focus on following up on reports and notifying Administrator and DON if no interventions have been implemented, and reporting injuries of unknown origin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 19 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Bay City 1800 13th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some The Director of Nursing initiated education with all staff on 7/27/23 on Resident Rights; topics includedintroducing self when entering resident's rooms, asking permission before providing care, and the resident's right to refuse care. The Director of Nursing initiated education with Licensed Nurses and CNAs on 7/29/23 with the following topics: reviewing the resident's [NAME] prior to performing ADL care to provide the correct level of assistance. The Director of Nursing initiated education with CNAs on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA feels that the charge nurse does not address a concern that is brought to their attention, and reviewing the resident's [NAME] prior to performing ADL care to provide the correct amount of assistance. Education will be completed by 7/30/23. Any staff member who did not receive the education will not be allowed to work their next shift until completed. Educational Packets/Training will be added to facility orientation. The facility does not currently utilize agency staff. Policy Review Change of Condition, Abuse/Neglect/Exploitation policy and procedure reviewed on 7/29/23 and required no changes. Monitoring The DON and ADON conducted grand rounds on 7/29/23 and 7/30/23 to ensure staff was providing the appropriate level of care, following the resident's [NAME], and compliant with observing resident's rights. On 7/30/23, the surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Interviews conducted on 7/30/23 with 4 staff revealed they had recently received training on abuse, change of condition, reporting of resident injuries, contacting supervisors, resident physicians, resident responsible parties, and completing documentation. They said if they were still concerned about the resident, they would talk to the Administrator or DON. Interviews and observations conducted on 7/30/23 with 4 residents revealed they were dressed, groomed, in their rooms which were clean and a comfortable temperature. They indicated that the staff were respectful, gentle with care, and provide care in a reasonable time. They had no concerns about their medications or treatments. Interviews conducted on 7/31/23 with 3 staff revealed they had recently received training on incontinence care, abuse/neglect, mechanical lifts, customer service, informing supervisors of resident condition concerns, and documentation. Interviews and observations conducted on 7/31/23 with 3 residents revealed they were dressed, groomed, in their rooms which were clean and a comfortable temperature. They indicated that the staff were respectful, gentle with care, and provide care in a reasonable time. They had no concerns about (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 20 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Bay City 1800 13th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 their medications or treatments. Level of Harm - Immediate jeopardy to resident health or safety Interview on 8/3/23 at 10:55 a.m. with the Administrator, she said she was responsible for every operation in the facility. She said she had been at the facility since 2/23. She said when she was notified of the 3 IJs, she immediately began working on the PORs. She said once she got them approved, the facility began in-servicing on 7/11/23 and again on 7/13 for all staff for education on communication, reporting change of condition, injuries of unknown origin, who to report to, the important of reporting, bruising, swelling, injuries, policy (change in condition and ANE) and nursing staff on 7/29/23. She said the DON also in-serviced nursing staff on 7/29/23 for reviewing the clinical database prior to performing ADLs so they knew what services to provide to each resident. She said on 7/29/23, all staff were trained for Resident Rights. She said it was important to train all staff to ensure residents were protected. She said staff was trained to communicate with residents, informed them of care as they provide services, and the right to be free from abuse and neglect. She said all nursing staff on mechanical lift were trained on 7/29/23. The Administrator said nursing staff that worked closely with CR#1 were included in the mechanical lift training. She said all nursing staff from all three shifts were trained on in-services and the training was conducted by the Rehab Director. She said the DON conducted the other mentioned trainings. She said the DON continue to ensure the training were effective through frequent monitoring. She said the DON conducted competency testing and return demonstration to ensure staff had understanding. The Administrator said she shared the finding with the QAPI on 7/29/23. She said she notified CR#1's Physician and the Medical Director directly after being notified of the IJs. Residents Affected - Some Interview on 8/3/23 at 11:25 am with the DON, she said she conducted 100% skin audits and there were no adverse findings on 7/13/23. She said on 7/29/23 in response to the IJ, she conducted a second 100% audit with ADON, and the MDS Nurse. She said the Medical Director was notified by the Administrator on 7/29/23 of the Immediate Jeopardy situation. She said she in-serviced all staff on Abuse and Neglect on 7/29/23. She said she also in-serviced nursing staff on reporting changes in resident condition with a focus on following up on reports of conditions to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt the charge nurse did not address a concern that was brought to their attention. She said staff were instructed to notify the Administrator and DON if no interventions had been implemented, and reporting injuries of unknown origin. Interview on 8/3/23 at 11:44 am with the RN I, she said she was responsible for MDS assessments for all resident in the facility. She said she updated care plans and coordinated drip drive (IV hydration/nutrition therapy). She said she had been at the facility about 7 years. She said she conducted 100% audit of the ADL care plans on 7/29/23 to ensure the appropriate level of care for each resident was accurate. She said it was a great experience for her because she was able to update about 3 or 4 care plans that required re-evaluation and the appropriate updates were made. She said communication improved between therapy staff and MDS Coordinator to ensure continuum of care was not interrupted. She said she completed all resident reviews by 8/2/23. Observation and Interview on 8/3/23 at 11:50 am with Resident #1 revealed a female resident that was well-groomed and well-dressed, playing a game on her iPad. She said a staff member (she could not recall who), had asked her if anyone had been rough with her during care and if she had ever been scared when nursing staff provided care. She said no one had ever been rough with her and she was not scared. She said she knew to tell the Administrator if someone ever mistreated her. Observation and Interview on 8/3/23 at 11:55 am with Resident #2 revealed a male resident, well-groomed and well-dressed conversing with his roommate while they both watch TV. He said a staff member (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 21 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Bay City 1800 13th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some (ADON) asked him if anyone had been rough with his during care and if he had any ever been scared when nursing staff provided care. He said no one had ever been rough with him and he was not scared. He said she knew to tell the Administrator if someone ever mistreated him. Observation and Interview on 8/3/23 at 12:05 pm with Resident #3 revealed a male resident, well-groomed and well-dressed having a conversation with his roommate. He said a staff member (ADON) asked him if anyone had been rough with him during care and if he had ever been scared when nursing staff provided care. He said no one had ever been rough with him and he was not scared. He said he knew to tell the Administrator if someone ever mistreated him. Observation and Interview on 8/3/23 at 12:15 pm with Resident #4 revealed a male resident, well-groomed and dressed in shorts and a t-shirt. He said a staff member (ADON) asked him if anyone had been rough with him during care and if he had ever been scared when nursing staff provided care. He said no one had ever been rough with him and he was not scared. He said he did not speak with the Administrator because she would tell him that she would return to speak with him but never would return. He said the Business Service Manager made rounds every morning to see how residents were doing. He said he would tell the Business Service Manager if anyone mistreated him. Observation and Interview on 8/3/23 at 12:20 pm with Resident #5 revealed a male resident, well-groomed and well-dressed watching TV. He said a staff member (ADON) asked him if anyone had been rough with his during care and if he had ever been scared when nursing staff provided care. He said no one had ever been rough with him and he was not scared. He said he knew to tell the Administrator if someone ever mistreated him. Interview on 8/3/23 at 1:11 pm with Med Tech A, she said she worked the morning shift (6am to 2pm). She said the DON trained all nursing staff on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt that the charge nurse did not address a concern that was brought to their attention, and reviewing the resident's clinical database prior to performing ADL care so they knew to provide residents with the appropriate level of care/services. She said she was also trained on the use and transfer with the Hoyer lift. Interview on 8/3/23 at 1:11 pm with LVN C, she said she worked the morning shift (6am to 2pm). She said the DON trained all nursing staff on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt that the charge nurse did not address a concern that was brought to their attention, and reviewing the resident's clinical database prior to performing ADL care so they knew to provide residents with the appropriate level of care/services. She said she was also trained on the use and transfer with the Hoyer lift. Interview on 8/3/23 at 1:11 pm with Restorative Aide A, she said she worked the morning shift (6am to 2pm). She said the DON trained all nursing staff on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt that the charge nurse did not address a concern that was brought to their attention, and reviewing the resident's clinical database prior to performing ADL care so they knew to provide residents with the appropriate level of care/services. She said she was also trained on the use and transfer with the mechanical lift. Interview on 8/3/23 at 1:11 pm with CNA B, she said she worked the morning shift (6 a.m. to 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 22 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Bay City 1800 13th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some p.m.). She said she provided care to CR#1. She said he required 2 persons assist for transfers with a Hoyer lift. She said he had a high level of care because he was dependent on assistance for all ADL's. She said she was trained due to the failure of reporting a change in condition for CR#1, so she was re-trained. She said the DON trained all nursing staff on 7/29/23 with the following topics: reporting changes of condition to include any bruising/swelling/injuries to the charge nurse, notifying the DON/ADON if the CNA felt that the charge nurse did not address a concern that was brought to their attention, and reviewing the resident's clinical database prior to performing ADL care so they knew to provide residents with the appropriate level of care/services. She said she was also trained on the use and transfer with the mechanical lift. The Administrator was informed the Immediate Jeopardy was removed on 8/3/23 at 1:50pm. The facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 23 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Bay City 1800 13th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for one (CR #1) of four residents reviewed for accidents, hazards, and supervision. -The facility failed to ensure CNA E did not provide incontinent for CR #1 by herself when care required two staff. These failures can place residents at risk of injury due to not being supervised properly. Findings include: Record review of CR #1's admission face sheet revealed an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included dementia (loss of memory, language, problem -solving and other thinking ability), quadriplegia (paralysis below the neck that affect all of a person's limbs), sepsis (the body's extreme response to an infection), and acute respiratory failure with hypoxia (a serious condition that makes it difficult to breath on your own and a condition where you do not have enough oxygen in the tissues in the body). Record review of CR #1's quarterly MDS assessment, dated 05/12/23, revealed the BIMS score was 00, which indicated severely impaired cognition. Further review of the MDS revealed he was always incontinent of bowel and bladder and required extensive assistance with two staff assist with bed mobility, transfers and toileting. Record review of CR #1's care plan initiated on 08/26/16 and revised on 10/04/22 revealed CR #1 required total assist by 2 staff for bed mobility and required total assistance of 1 staff for toileting. Observation and Interview on 07/13/23 at 9:25 a.m., CR #1 was lying on his back in a hospital bed. He responded to his name. CR #1's left arm was swollen around the elbow, and he had a bruised left arm, which was dark purple with some yellow discoloration, and the inner arm was purple and red and had bruised areas on his left chest. CR #1's nurse from the hospital was in the room when the surveyor asked him what had happened to his arm, and he said he had fallen. When asked how he fell, the surveyor could not understand what he was saying. Interview on 07/13/23 at 9:32 a.m. with HHSC interpreter (6023) because CR#1 spoke Spanish. CR #1 told the interpreter in Spanish that he fell from his chair, and when the interpreter asked him how he fell, the interpreter said he could not understand what CR #1 was saying. Interview on 07/13/23 at 12:24 p.m., CNA A said she worked with CR #1 in the past, and CR #1 was a two-person with mechanical lift and bed mobility and during incontinent care. She said CR #1 could not do anything for himself; the staff had to do everything for CR #1. During a telephone interview on 07/13/23 at 1:07 p.m., LVN W said CNA E called and told her CR #1 was having a breathing problem on 07/10/23 at about 8:00p.m., and when she saw CR #1, he was breathing shallow, and she checked his O2 sat, it was 85%, and she called 911 to take the resident to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 24 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Bay City 1800 13th St Bay City, TX 77414 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hospital. She said the aide had just finished changing the resident by herself, but the resident required two-person assistance, and she did not tell her if the resident fell or hit any part of his body on the bed. She said she did not do any skin assessment on the resident because the aide had cleaned him up, and he was good to go, and she sent him out. Interview on 07/13/23 at 1:42 p.m., RN I said CR #1 was very stiff and could not turn himself even if he wiggled himself; he could not hurt himself on the side rails. She said the resident needed two people to assist with incontinent care in bed and for transfers. She said if one aide provided the care, she did not follow the CR #1 plan of care which could cause an injury to CR #1 During a telephone interview on 07/13/23 at 1:59 p.m., CNA E said she went into CR #1's room, and he was not looking right on 07/10/23 bout 8:00 p.m. She called LVN W, and the nurse checked his oxygen, which was 85%. She said she provided incontinent care for CR #1 by herself because that was her first day of orientation on the floor, and she did not know he was two persons assist. Interview on 07/13/23 at 2:41 p.m. CNA S said CNA E went and changed CR #1 by herself, but CR#1 needed two staff assistance. CNA S said forgot to tell CNA O that CR #1 needed to person assistance for incontinent care and CNA O did not tell her she was going to provide incontinent for CR #1. She said CR #1 could get hurt if one person provided care. Interview on 07/13/23 at 3:09 p.m., the DON said CR #1 needed two-person assistance with transfer and bed mobility, and two staff should have provided the incontinent care if it was care planned for two staff. Record review of the facility policy on accident and incident - investigating and reporting created 09/19/21 read in part . all accidents or incidents involving residents . occurring on our premises shall be investigated and reported . policy interpretation and implementation . #1 . the charge nurse and /or the department director or supervisor shall promptly initiate and document investigation of the incident . #2g. the time the injured person's attending physician was notified as well as the time the physician responded and his instructions . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 25 of 25