Health inspection·January 12, 2024

F 0656 continence. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's December 2023 Bowel and Bladder Elimination Record revealed the following: Bowel Elimination: 6 AM-6 PM - The resident was noted not to have a bowel movement on 12/1/23, 12/13/23 and 12/18/23; resident's bowel movement was constipated/hard/putty-like consistency noted on 12/2/23, 12/19/23 and 12/23/23; all other dates the resident was noted to have a normal bowel movement. Residents Affected - Some Further review of the Bowel Elimination Record revealed, bowel elimination for Resident #1 was not documented 6 PM-6 AM on 12/5/23, 12/13, 12/15, 12/18, 12/20, and 12/22/23. The resident was noted not to have a bowel movement on 12/4/23, 12/6, 12/10, 12/11, 12/14, 12/19, 12/21 and 12/24/23; resident's bowel movement was constipated/hard/putty-like consistency noted on 12/8/23 and 12/9/23; resident was noted to have a normal bowel movements 12/1-12/3/23, 12/7/23, 12/12/23, 12/16-12/17/23 and 12/23/23. Record review of Resident #1's electronic health record indicated, the resident's MD was notified around 7:00 PM on 12/23/23, the resident was non-responsive to verbal touch or painful stimuli and had a temperature of 101.8 and O2 stats at 84%. The MD ordered for the resident to be sent to the hospital via emergency services. Further review of electronic record revealed an SBAR (Change in Condition Assessment) was documented, and the responsible party and DON were notified. Record review of Resident #1's electronic health record revealed the hospital faxed a 69-page clinical update on Resident #1 to the facility, on 12/25/23, after he was admitted to the hospital on [DATE]. Further review of the clinical update revealed the following: Emergency Department Provider Documentation, dated 12/24/23 at 10:51 indicated, At 4:33 AM, Resident #1's vital signs were as follows: Temperature: 102.1, Pulse: 94, Resp.: 45, B/P: 134/91, Pulse Ox., 93, with oxygen delivery via nasal cannula .The Emergency Department Documentation revealed the following scheduled medications: .Valproic Acid 250 Mg/5 (Depakene Syrup*), 5 ML PO BID; Docusate Liquid, 10 MG PEG BID. Scheduled PRN: Acetaminophen, 1,000 MG PO Q8H PRN for pain; Docusate Liquid 100 MG/10 ML LIQ No Conflict Check, 100 MG PEG BID for Constipation, #100 M/L 0 Refills *Valproic Acid 250 MG/5 ML (Depakene Syrup)* 250 Mg/5 MI Solution, 5 ML PO, BID for Mood Stabilization . .History & Physical indicated, Resident #1 was intubated (insertion of tub to open the trachea for air) upon arrival due to respiratory rate. Labs showed elevated levels of sodium in the blood, elevated creatinine, decreased kidney function, and elevated lactic acid. Chest x-ray showed right perihilar airspace disease (Acute or chronic condition of alveolar airspaces filled by fluid, pus, blood, cells, or other material present consolidated opacity on chest imaging) in the right upper lobe, and mild left lower lobe atelectasis (mild collapse of the left lower part of the lung). The resident had a new or unexplained change in mental status. Sepsis (life threatening infection) without shock indicated by elevated white blood cell count, increased lactic acid, and white blood cell count on arrival to the ER, and new diagnosis of pneumonia; due to severe hypernatremia (sodium in the blood due to insufficient drinking of water) resident was started on D5W NS 100 ml/hr. Hyperosmolar Hyperglycemia State (life-threatening diabetic complication when blood glucose levels are too high for a long period, leading to severe dehydration and confusion) related to elevated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 2 of 18 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 01/12/2024 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 0656 blood sugar level (500) on arrival; the resident had no history of diabetes in the past. Level of Harm - Minimal harm or potential for actual harm Hypernatremia (electrolyte problem caused by a decrease in total body water due to high levels of sodium in the blood) could be due to dehydration; Resident #1 had a water deficit around 7 liters; had past history of Hypernatremia probably related to TBI and placement, resident may not have been getting enough fluid. Residents Affected - Some Acute Kidney Injury (sudden and often irreversible reduction in kidney function) likely due to dehydration; the resident's creatinine level was 2.14 and his baseline level was 1; and ordered to continue on D5W due to the hypernatremia diagnosis. The Treatments & Prophylaxis indicated, Resident #1 had a foley catheter inserted on 12/24/23. The History of Present Illness revealed, Resident #1 arrived in respiratory distress and was placed on a mechanical ventilator in the ER. He was noted to have severe electrolyte abnormalities including Hypernatremia and Acute Kidney Injury and was admitted to ICU for critical care management. Resident #1's MD consultation on 12/24/23 at 11:51 further revealed, History of Chief Complaint: .His sodium is extremely elevated with a reading at about 167 in the setting of his glucose being in the 500 range. Corrected sodium level is even further elevated perhaps close to 180 .D5W (Dextrose 5% in water is injected into a vein through an IV to replace lost fluids and provide carbohydrates to the body) at 100 mL an hour and repeat lab work in the afternoon. Patient seems very dehydrated .Assessment and Plan .acute hypoxic respiratory failure in the setting of pneumonia and severe hydration. Once patient is improved and discharged back, would need aggressive proper hydration given his traumatic brain injury. May not be able to get water or ask for water on a regular basis and this may need to be monitored with periodic BNP (blood test to measure the levels of a protein in the bloodstream) as well. A Radiology Report for Resident #1, dated 12/24/23 at 11:18, indicated the following: CT scan of the chest, abdomen, and pelvis was performed without contrast .Findings: .Gastrointestinal: Enteric tube (support device placed for feeding patients who cannot swallow or decompressing the GI tract) terminates in the stomach. Well-positioned percutaneous gastronomy tube (feeding tube often called PEG tube or G tube). Small catheter in the rectum. Very large amount of fecal material in the distal sigmoid colon and rectum (Fecal impaction or Fecaloma - A mass of hardened feces that remains in the colon or rectum; contractions that normally move feces along are not able to eject the hardened mass). Small to moderate amount throughout the rest of the colon. No evidence of small bowel obstruction or perienteric inflammation .Bladder/Reproductive: The urinary blader is decompressed by a balloon catheter .Impression: 2. Very large amount of fecal material in the distal sigmoid colon and rectum. Small to moderate amount throughout the rest of the colon. Correlate for constipation and potential fecal impaction. Record review of Resident #1's electronic health record revealed the hospital faxed a 66-page clinical update on Resident #1 to the facility, on 12/31/23, after he was transferred from one hospital, and admitted to another hospital on [DATE]. Further review of the clinical update revealed, Resident #1 was .transfer from hospital with a diagnosis of fecal impaction with possible bowel obstruction with dilated sigmoid colon up to roughly 10 cm .He was extubated (removing endotracheal tube used for breathing) and now currently on room air. Also treated for Sepsis, hypernatremia due to severe dehydration with associated Acute Kidney Injury which has resolved .Physical Exam: . Gastrointestinal: slightly tender, distended, hypoactive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 3 of 18 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 01/12/2024 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 0656 bowel sounds, PEG tube capped. Level of Harm - Minimal harm or potential for actual harm Further review of the Clinical Update revealed Recommendations, dated 12/28/23 as follows: .Transferred to hospital as there was a concern for an obstruction, severe impaction .likely has chronic fecal impaction .BID enemas ordered .Once complete should be able to resume tube feeds and Miralax BID .Chronic constipation and impaction. Low concern for stercoral ulcer at this point. However, need to prevent one from occurring. No need to repeat a CT abdomen/pelvis at this time. Residents Affected - Some An MD Consultation, dated 12/29/23, revealed the resident's abdomen was soft and distended. Further review of the MD Consultation indicated, Assessment and Plan: 1 .Start patient on D5W at 125 cc/hour (cubic centimeters per hour)for water deficit of 3.3 L .2 .Continue IV fluid hydration. 3. Fecal impaction with suspected bowel obstruction. Surgery was consulted. Placed on enemas followed by General Surgery .5. Nutrition. Enteral tube feeds are currently on hold due to bowel obstruction . An MD Consultation, dated 12/30/23, revealed the resident had multiple stools overnight, was restarted on enteral tube feeds, and his abdomen was soft, nontender and mildly distended. Further review of the MD Consultation indicated, Assessment and Plan: 1 .Remains on D5W 125 mL/hour. We will start free water flushed 200 q.2 3. Fecal impaction with suspected bowel obstruction. Surgery was consulted. Treated with enemas and laxatives, improved. 4. Recent respiratory failure .Remains on antibiotic therapy. Further review of the clinical update revealed the following: Special Instructions, dated 12/31/23 at 4:17 PM indicated, .Discharge to SNF: Special Instructions: ok to d/c to SNF; meds per list; resume tube feed diet/aspiration precautions; PT/OT/ST: continue regular bowel regimen; follow up snf pcp; follow up nephrology and GI as per them. Discharge Medications: New medications to start taking Amoxicillin-potassium clavulanate oral tablet 875-125 mg - Take 1 EA orally twice daily; Ipratropium-Albuterol 0.5-2.5 Nebulization solution 0.5-2.5(3) mg/3ml - Take inhalation every 4 hours as needed for shortness of breath. Last dose given: 12/31/23 at 2:00 PM; Mineral Oil Oral - Take 30 ml tube once a day as needed for constipation. Last dose given: 12/31/23 at 3:17 AM .All medications must be taken as directed. Contact your physician before stopping medications. Record review of Resident #1's orders, dated as of 01/11/24, did not reveal orders to address the resident's foley catheter; past history of dehydration and recent diagnosis of severe dehydration; or monitoring/observations related the resident's past history of constipation and recent diagnosis of fecal impaction. Further review of Resident #1's electronic health records record revealed, the following orders, dated as of 01/11/24: Order Date: 1/04/24, Mineral Oil Give 30 ml via G-Tube every 24 hours as needed for Bowel Management Order Date: 1/04/24, MiraLax Oral Packet 17 GM (Polyethylene Glycol 3350) Give 1 packet via G-Tube every 24 hours as needed for Bowel Management Order Date: 1/04/24, Fleet Enema Rectal Enema (Sodium Phosphates) Insert 1 applicator rectally every 24 hours as needed for Bowel Management Order Date: 1/04/24, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 3 ml inhale orally every 4 hours as needed for Wheezing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 4 of 18 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 01/12/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Order Date: 1/04/24, *Enteral Feeding Site Care* every night shift for observations Cleanse with Normal saline, pat dry, apply fenestrated dressing daily and as needed. Order Date: 1/05/24, Valproic Acid Oral Solution 250 MG/5ML (Valproate Sodium) Give 5 ml via G-Tube two times a day related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION give 5ml to equal 250mg Order Date: 1/05/24, Amoxicillin-Pot Clavulanate Tablet 875-125 MG Give 1 tablet via G-Tube two times a day for bacterial infection for 7 Days. Order Date: 1/05/24, Docusate Sodium Liquid 50 MG/5ML Give 10 ml by mouth two times a day for Constipation give 10mg to equal 100mg Order Date: 1/05/24, Lexapro Oral Tablet 5 MG (Escitalopram Oxalate) Give 1 tablet via G-Tube one time a day related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED Order Date: 1/09/24, NPO (Nothing by Mouth) diet NPO texture, NPO consistency Order Date: 1/09/24, *Enteral Order*- Monitor resident for signs/symptoms of misplacement of enteral tube: Difficulty with medication/feeding/water Order Date: 1/10/24, License nurse to monitor: *ABDOMINAL WOUND* for any abnormalities or changes to surrounding skin for s/s of infection, pain associated with site. Document plus (+) sign for no observed changes and a minus (-) sign for any observed changes, notify MD, and document findings in a progress note. every shift for observations. Record Review of Resident #1's Baseline Care Plan, dated 01/04/24, did not reveal goals or interventions to address the resident's foley catheter; history of dehydration and recent diagnosis of severe dehydration; or monitoring/observations related the resident's past history of constipation and recent diagnosis of fecal impaction. Further review of the baseline Care Plan indicated, Resident #1 required one-person physical assist for all ADLs; was to receive Physical and Occupational Therapy; always urinary and bowel incontinent, and had an indwelling catheter; and had a diet order for nothing by mouth, and Jevity 1.5 via his PEG tube. In an interview with LVN B on 01/11/24 at 4:52 PM, she said she worked at the facility for about 3 years and had worked all over the facility at different times. She said when she was assigned to her regular hall, she was the nurse responsible for providing care to Resident #1. She said Resident #1 was nonverbal, was good as long as he was kept dry and had a PEG tube. She said Resident #1 did not have a history of constipation, nor did he have a history of dehydration. LVN B said he did not have a history of dehydration because he received nutrition and fluids through his feeding tube. LVN B said she could not recall the last time she reviewed Resident #1's care plan. She said she did not know who was responsible for reviewing or updating a resident's care plan. She said she imagined it was the charge nurse or the DON's responsibility. She said she provided care to residents, based on the orders in the electronic health record. LVN B said she received updates on resident changes during report from nurses during shift change. LVN B said she was aware Resident #1 had been in the hospital and returned to the facility a few days ago. LVN B said she heard Resident #1 was hospitalized for an abscess, but LVN A was not sure who told her about the abscess. She said she was not aware Resident #1 was diagnosed with severe dehydration and fecal impaction. LVN B said Resident #1's recent diagnoses would not have changed the care the resident was currently receiving because it was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 5 of 18 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 01/12/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some standard to monitor Resident #1 for signs and symptoms of dehydration and constipation related to his PEG-tube. She said Resident #1 did not have a catheter before he went to the hospital but did have one in place now. She said the resident had orders in place for his catheter but did not know what diagnosis resulted in the catheter. She said now that Resident #1 had a catheter, it made it easier to track his urinary output. She said bowel movements and urinary output was documented in Resident #1's electronic health record by CNA's. She said she did not know who was responsible for reviewing Resident #1's bowel movements or urinary output. She said the CNA's were very good about verbally communicating with the nurses about issues with the residents. She said the CNA's were aware they were to notify a nurse when a resident went 48 hours without a bowel movement. She said she was not aware Resident #1 ever had orders for nurses to monitor his bowel movements. She said she had not reviewed Resident #1's bowel and bladder elimination records before, or since he had returned from the hospital. She said she was responsible for making sure residents with PEG-tubes did not aspirate and checked for residual air to make sure their stomachs were not full. LVN B said she performed those tasks for every resident that had a g-tube before LVN B administered every medication dose. She said all this information was documented on the resident's MAR. She said when completing the MAR for a resident with a PEG-tube, certain yes/no questions like did you assess bowel sounds, and did you assess lung sounds, were triggered and had to be answered before being allowed to move forward on the MAR. LVN B said if a resident went a full 8 hour shift without urinating, she would complete an assessment on the resident and notify the resident's MD. She said if a resident went two days without a bowel movement, they would also need to be assessed. LVN B said she would check for bowel distention and then contact the doctor to see if a catheter needed to be put in, or if x-rays needed to be ordered for the resident. She said she would check the resident's vital signs and ask the resident how much they had to eat or drink. She said she would also check with the CNA's and ask about their consumption. She said failure to document, assess or review Resident #1's changes in both urinary and bowel output put the resident at risk of bladder eruption, bowel obstruction, and pain and discomfort at the very least. She said information about residents like this and signs and symptoms to look out for were verbally discussed all throughout the shift with the necessary staff and during shift change. She said she would instruct CNA's to be mindful of the color, amount, or any odor related to urinary output. She said the CNA's knew to report issues like this to the nurse immediately. She said the CNA's know they could also report to the DON. She said all nurses could assist in the care of any resident and had access to review and document on any resident's electronic health record. An observation of Resident #1 on 01/11/24 at 6:28 PM revealed the following: The resident wore a gown that tied at the back of his neck. His face was clean in appearance, his lips were slightly chapped. The resident curled his body into a slight fetal position as LVN A removed the sheet that covered his body and raised his gown and exposed the resident's abdomen. He wore what appeared to be gown that tied at the back of his neck. He was clean in appearance; his lips were slightly chapped, and the resident wore a brief underneath the gown. Resident #1's PEG-tube site was clean and appeared to be operating appropriately. LVN A pulled the resident's gown down and placed the sheet back over his body. Plastic tubing containing what appeared to be urine, could be seen on the lower left side of the resident's bed after the sheet was placed back. In an interview with LVN A on 01/11/24 at 6:28 PM, she said she had worked for the facility for a few months and was typically the nurse on Resident #1's hall during the 6:00 PM to 6:00 AM shift, unless she was assigned to work a different hall. She said even though the resident was nonverbal, he still communicated with LVN A in his own way. LVN A said when she did her first round on Resident #1, she always asked him if he was doing okay, and he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 6 of 18 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 01/12/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some would usually give her a thumbs up. She said she had heard mention of the resident whispering words, but she never observed it for herself. LVN A said the resident had returned from the hospital a few days ago and had not fully returned to behaving like himself. She said the resident seemed as if he had even more of a cognitive decline since going to the hospital. LVN A said nothing had changed nor had she been made aware of changes or updates to the care or treatment for Resident #1. She said the resident was readmitted to the facility with a foley catheter in place. LVN A said she was not sure what diagnosis the resident returned with to have a catheter. She said she did not know whether Resident #1 had orders or care planned interventions for the foley catheter. She said it was standard for all residents with catheters to have their urinary intake and output monitored. LVN A said CNA's were responsible for documenting both urinary and bowel movements in the resident's electronic health record. She said the only time she would monitor or assess the resident for issues with the catheter or bowel movements, was if during her interaction with the resident, she noticed a problem or if a CNA notified her of an issue. She said the CNA's were very good about notifying the nurses of resident issues. LVN A said all the CNA's knew if a resident went longer than 3 days without having a bowel movement that a nurse needed to be notified. She said she did not specifically review the resident's Urinary and Bowel Elimination Record because that was something the CNA's documented. LVN A said as far as she knew, Resident #1 did not have a history of dehydration because he received fluids and nutrition via his PEG-tube. She said she did not know Resident #1 to have a history of constipation either. LVN A said she did not know Resident #1 was treated for severe dehydration or fecal impaction during his recent hospital stay. LVN A said the only update she received on Resident #1 when he returned to the facility, was report from the nurse she relieved the next time she cared for Resident #1 after he was readmitted . LVN A said she was the nurse in charge of Resident #1's care when he was sent out to the hospital in December. She said she never observed Resident #1 exhibiting signs or symptoms of dehydration, constipation or fecal impaction. She said if the resident was impacted, he would have had a distended stomach and likely expressed discomfort. She said she was never notified of any constipation issues either. LVN A said listening for bowel sounds was part of providing treatment to Resident #1 via PEG-tube before he went to the hospital. She said if she had noticed signs or symptoms of constipation or a distended stomach, she would have performed an assessment, completed an SBAR in the resident's electronic health record, notified the MD and followed any orders or directives, and notified the DON. In an interview with the DON on 01/11/24 at 7:41 PM, she said she worked at the facility since the week of Thanksgiving 2023. She said Resident #1 returned to the facility from the hospital on either 01/04/24 or 01/05/24. She said she could not recall off the top of her head the resident's medical history, or his recent diagnoses from the hospital. She said there were no changes or updates made to the care Resident #1 was receiving from staff. She said she was aware Resident #1 was readmitted to the facility with a foley catheter in place. She said she could not recall off the top of her head what diagnosis Resident #1 had been given for the insertion of the catheter. She said she would have to look at the resident's chart. She said she was waiting on an order from Resident #1's doctor to d/c his foley catheter. She said the nurses on duty at the time residents returned to the facility were responsible for completing readmission assessments and developing baseline care plans. She said she did not know who completed either when Resident #1 returned to the facility. She said she reviewed the resident's readmission assessment and baseline care plan but could not recall specifics of either. She said the only thing she remembered was Resident #1's readmission assessment did not include the resident's foley catheter. She said the resident's baseline care plan did include Resident #1's catheter She said she addressed the error on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 7 of 18 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 01/12/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some readmission assessment with the staff to be corrected but did not document anything specific on the error or the conversation she had with the staff. She said other than the placement of the catheter, nothing had changed in the care and treatment Resident #1 was receiving since being readmitted to the facility. She said the facility was still within their timeframe for completing Resident #1's assessments and finalizing his care plan since being readmitted . She said she did not know off the top of her head what the facility's policy was on assessments or care plans, but that was what the facility was following. She said the ADON was typically responsible for reviewing readmission assessments and baseline care plans. She said the ADON's last day was 01/02/24, so ultimately, it was her responsibility to review assessments and care plans. She said she did not see an issue with the Resident #1's baseline care plan explicitly including his recent diagnoses of severe dehydration and bowel impaction because these are all things still being monitored by the staff. She said urinary output and bowel movements were being monitored for the resident. She said the only major change for Resident #1 was that he returned with a catheter and reiterated that nothing had changed in the care he was currently receiving. She said she did not know Resident #1 had a documented history of dehydration and constipation. She said she did not know prior to going to the hospital, Resident #1 was care planned for IV hydration therapy and for nurses to monitor his bowel movements. She said Resident #1's recent diagnoses of impaction and severe dehydration should have been care planned. She said the resident was put at risk of further impaction if his bowel movements were not appropriately monitored. She said Resident #1 was also at risk for constipation, impaction and Sepsis by not having his recent impaction care planned. She said the resident was at risk of further dehydration by not having his recent severe dehydration diagnosis care planned. In an interview with the DON on 01/12/24 at 11:10 AM, she said the third row of Resident #1's December 2023 Bowel and Bladder Elimination Record was not necessary for CNA's to complete, unless the resident had experienced additional urinary output or bowel movement after the initial one documented during a shift. She said the blank spaces that appeared within the first two rows of both the bowel and bladder record were times Resident #1's bowel or bladder elimination were not documented by staff in his electronic health record. In an interview with LVN C on 01/12/24 at 11:32 AM, she said she worked at the facility for four months and was promoted to the position of treatment nurse two weeks ago. She said prior to two weeks ago, she was regularly assigned to provide care to Resident #1. She said she was not completely familiar with Resident #1's care plan. She said she probably had, but could not say with 100% certainty that she had seen a resident care plan. She said she knew Resident #1 received tube feedings, needed a lot of mouth care, and that his lips got really dry. She said she was not sure, but believed Resident #1 did have a history of constipation. She said she did not ever review Resident #1's bowel movement records in his electronic health record because the CNA's took care of that. She said she did not know if the information entered by the CNA's was reviewed by nurses. She said for any resident, she relied on the CNA's to give her information about their bowel movements. She said the CNA's were very good about monitoring resident bowel movements and notifying nurses of any issues. She said she did not know of Resident #1 having a history of dehydration. She said she believed nurses were supposed to review resident care plans, but she was still learning how to navigate the electronic health records. She said she did not know the reason for Resident #1's recent hospitalization or if any changes had been made to the care he was currently receiving because she only handled wound treatments. She said Resident #1 was currently being monitored for a wound discovered prior to recent hospitalization. She said she did not know Resident #1 had been recently diagnosed with severe dehydration or constipation. She said dehydration could have affected an individual with wounds. She said the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 8 of 18 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 01/12/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm treatment nurse position was new and something the facility had just created. She said she did not know what risk Resident #1 could have been put at by not having dehydration appropriately care planned and monitored. She said no one gave nurses new information or updates on changes with residents. She said she relied on verbal communication with other nurses and CNA's, and doing her best to review resident electronic health records to stay up to date on the care she was to provide to residents. Residents Affected - Some In an interview with CNA B on 01/12/24 at 1:28 PM, she said she worked at the facility for almost three years. She said CNA's were responsible for documenting bowel movements and bladder function for every resident. She said all the CNA's knew their residents well. Resident #1 had a bowel movement every day. She said sometimes his bowel movements were runny, sometimes formed, soft, but never hard. She said she did not know Resident #1 to have a history of constipation. She said the resident had a bowel movement every time she worked with him. She said the resident did not have a history of dehydration because he received hydration through his feeding tube. She said Resident #1 did receive a lot of mouth care. She said she would not let a resident go more than two days without having a bowel movement and letting a nurse know. She said she did not know if the nurses reviewed residents bowel and bladder information in their electronic health records. In an interview with the MD on 01/12/24 at 1:42 PM, he said he was Resident #1's primary care physician. He said he was aware Resident #1 had recently been hospitalized . He said he did not have access to previously entered information and could only see active orders for the resident. He said from what he could recall, prior to going to the hospital, Resident #1 should have been on an IV hydration therapy program. He said he was notified Resident #1 was returned to facility but did not remember the exact date. He said Resident #1 currently had an order for mineral oil every 24 hours and Miralax every 24 hours as needed for bowel management. He said[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 9 of 18 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 01/12/2024 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 4 residents (Resident #1) reviewed for quality of care. Residents Affected - Some The facility failed to accurately modify interventions for Resident #1 when he was readmitted to the facility on [DATE] with a foley catheter, was recently hospitalized due to severe dehydration and fecal impaction, and a history of dehydration and constipation. These failures placed residents at risk for new development or worsening of existing infection, pain, and decreased quality of life. Findings included: Record review of Resident #1's face sheet dated 01/11/24 revealed a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included Displaced Fracture of Greater Tuberosity of Right Humerus (occurs due to trauma or shoulder dislocation, a boney disruption to the rotator cuff tendons around the shoulder); Cognitive Communication Deficit (difficulty with thinking and how a person uses language); Unspecified Foreign Body in other parts Respiratory Tract causing Asphyxiation (foreign bodies in the airway causing choking); Aphasia (loss of ability to understand or express speech, caused by brain damage); and, Traumatic Brain Injury without loss of consciousness (injury to the brain caused, at the moment of impact, by a blow or jolt to the head from blunt or penetrating trauma). Record review of Resident #1's Quarterly MDS assessment dated [DATE], indicated the resident rarely/never had the ability to express ideas and wants. The resident rarely/never understood verbal content, as a result the Brief Interview for Mental Status was skipped; the resident was dependent or required the assistance of two or more persons to complete all functional abilities and goals; He was always urinary and bowel incontinent and not on a current toileting program to manage bowel continence. Further review of the MDS did not reveal the resident had a foley catheter. Record Review of Resident #1's Care Plan, revised on 11/26/23, indicated the resident was on IV hydration therapy with a goal of no dehydration; at risk of dehydration related to Traumatic Brain injury and cognitive impairment and received total nutrition/hydration via feeding tube; he had a history of constipation and was at risk of impaction and bowel obstruction due to being bedbound. After three days without a bowel movement, a bowel assessment was to be performed and abnormal findings reported to the resident's doctor. Nurse's (LVNs and RNs) were to monitor the resident's bowel movements for amount and consistency. Record review of Resident #1's electronic health record indicated, the resident's MD was notified around 7:00 PM on 12/23/23, the resident was non-responsive to verbal touch or painful stimuli and had a temperature of 101.8 and O2 stats at 84%. The MD ordered for the resident to be sent to the hospital via emergency services. Further review of electronic record revealed an SBAR (Change in Condition Assessment) was documented, and the responsible party and DON were notified. Record review of Resident #1's electronic health record revealed the hospital faxed a 69-page clinical update on Resident #1 to the facility, on 12/25/23, after he was admitted to the hospital on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 10 of 18 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 01/12/2024 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 - Minimal harm or potential for actual harm Residents Affected - Some [DATE]. Further review of the clinical update revealed the following: Emergency Department Provider Documentation, dated 12/24/23 at 10:51 indicated, At 4:33 AM, Resident #1's vital signs were as follows: Temperature: 102.1, Pulse: 94, Resp.: 45, B/P: 134/91, Pulse Ox., 93, with oxygen delivery via nasal cannula .The Emergency Department Documentation revealed the following scheduled medications: .Valproic Acid 250 Mg/5 MI (Depakene Syrup*), 5 ML PO BID; Docusate Liquid, 10 MG PEG BID. Scheduled PRN: Acetaminophen, 1,000 MG PO Q8H PRN for pain; Docusate Liquid 100 MG/10 ML LIQ No Conflict Check, 100 MG PEG BID for Constipation, #100 M/L 0 Refills, Provider FNP-C 5/4/22; .*Valproic Acid 250 MG/5 ML (Depakene Syrup)* 250 Mg/5 MI Solution, 5 ML PO, BID for Mood Stabilization . .History & Physical indicated, Resident #1 was intubated upon arrival due to respiratory rate. Labs showed elevated levels of sodium in the blood, elevated creatinine, decreased kidney function, and elevated lactic acid. Chest x-ray showed right perihilar airspace disease (Acute or chronic condition of alveolar airspaces filled by fluid, pus, blood, cells, or other material present consolidated opacity on chest imaging) in the right upper lobe, and mild left lower lobe atelectasis (mild collapse of the left lower part of the lung). The resident had a new or unexplained change in mental status. The Diagnosis, Assessment & Treatment Plan of the clinical update, revealed the following: Resident #1 was diagnosed with Acute Hypoxic Respiratory Failure (air sacs of the lungs cannot release enough oxygen into the blood, likely due to conditions that affect lung function) due to pneumonia; intubated in the ER due to respiratory failure; Resident #1's elevated lactic acid level, white blood cell count and fever met sepsis criteria; he received 2 NS bolus in the ER; and, Critical Care was consulted. Sepsis without shock indicated by elevated white blood cell count, increased lactic acid, and white blood cell count on arrival to the ER, and new diagnosis of pneumonia; due to severe hypernatremia resident was started on D5W NS 100 ml/hr. Hyperosmolar Hyperglycemia State (life-threatening diabetic complication when blood glucose levels are too high for a long period, leading to severe dehydration and confusion) related to elevated blood sugar level (500) on arrival; the resident had no history of diabetes in the past. Hypernatremia (electrolyte problem caused by a decrease in total body water due to high levels of sodium in the blood) could be due to dehydration; Resident #1 had a water deficit around 7 liters; had past history of Hypernatremia probably related to TBI and placement, resident may not have been getting enough fluid. Acute Kidney Injury (sudden and often irreversible reduction in kidney function) likely due to dehydration; the resident's creatinine level was 2.14 and his baseline level was 1; and ordered to continue on D5W due to the hypernatremia diagnosis. Elevated Trops (signs of heart damage) likely due to type 2 NSTEMI (acute imbalance in the body's oxygen supply and demand, not related to an otherwise unstable coronary artery); cardiology was consulted. The Treatments & Prophylaxis indicated, Resident #1 had a foley catheter inserted on 12/24/23. The History of Present Illness revealed, Resident #1 arrived in respiratory distress and was placed on a mechanical ventilator in the ER. He was noted to have severe electrolyte abnormalities including Hypernatremia and Acute Kidney Injury and was admitted to ICU for critical care management. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 11 of 18 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 01/12/2024 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 - Minimal harm or potential for actual harm Residents Affected - Some Resident #1's MD consultation on 12/24/23 at 11:51 further revealed, History of Chief Complaint: .His sodium is extremely elevated with a reading at about 167 in the setting of his glucose being in the 500 range. Corrected sodium level is even further elevated perhaps close to 180 .D5W (Dextrose 5% in water is injected into a vein through an IV to replace lost fluids and provide carbohydrates to the body) at 100 mL an hour and repeat lab work in the afternoon. Patient seems very dehydrated .Assessment and Plan .acute hypoxic respiratory failure in the setting of pneumonia and severe hydration. Once patient is improved and discharged back, would need aggressive proper hydration given his traumatic brain injury. May not be able to get water or ask for water on a regular basis and this may need to be monitored with periodic BNP (blood test to measure the levels of a protein in the bloodstream) as well. A Radiology Report for Resident #1, dated 12/24/23 at 11:18, indicated the following: CT scan of the chest, abdomen, and pelvis was performed without contrast .Findings: .Gastrointestinal: Enteric tube (support device placed for feeding patients who cannot swallow or decompressing the GI tract) terminates in the stomach. Well-positioned percutaneous gastronomy tube (feeding tube often called PEG tube or G tube). Small catheter in the rectum. Very large amount of fecal material in the distal sigmoid colon and rectum (Fecal impaction or Fecaloma - A mass of hardened feces that remains in the colon or rectum; contractions that normally move feces along are not able to eject the hardened mass). Small to moderate amount throughout the rest of the colon. No evidence of small bowel obstruction or perienteric inflammation .Bladder/Reproductive: The urinary blader is decompressed by a balloon catheter .Impression: 2. Very large amount of fecal material in the distal sigmoid colon and rectum. Small to moderate amount throughout the rest of the colon. Correlate for constipation and potential fecal impaction. Record review of Resident #1's electronic health record revealed, on 12/31/23, the hospital faxed a 66-page clinical update on Resident #1 to the facility after he was transferred from one hospital, and admitted to another hospital on [DATE]. Further review of the clinical update revealed, Resident #1 was .transfer from hospital with a diagnosis of fecal impaction with possible bowel obstruction with dilated sigmoid colon up to roughly 10 cm .He was extubated and now currently on room air with Spo2 98%. Also treated for Sepsis, hypernatremia due to severe dehydration with associated Acute Kidney Injury which has resolved .Physical Exam: . Gastrointestinal: slightly tender, distended, hypoactive bowel sounds, PEG tube capped. Further review of the Clinical Update revealed Recommendations, dated 12/28/23 as follows: .Transferred to hospital as there was a concern for an obstruction, severe impaction .likely has chronic fecal impaction .BID enemas ordered .Once complete should be able to resume tube feeds and Miralax BID .Chronic constipation and impaction. Low concern for stercoral ulcer at this point. However, need to prevent one from occurring. No need to repeat a CT abdomen/pelvis at this time. An MD Consultation, dated 12/29/23, revealed the resident's abdomen was soft and distended. Further review of the MD Consultation indicated, Assessment and Plan: 1 .Start patient on D5W at 125 cc/hour for water deficit of 3.3 L .2 .Continue IV fluid hydration. 3. Fecal impaction with suspected bowel obstruction. Surgery was consulted. Placed on enemas followed by General Surgery .5. Nutrition. Enteral tube feeds are currently on hold due to bowel obstruction . An MD Consultation, dated 12/30/23, revealed the resident had multiple stools overnight, was restarted on enteral tube feeds, and his abdomen was soft, nontender and mildly distended. Further review of the MD Consultation indicated, Assessment and Plan: 1 .Remains on D5W 125 mL/hour. We will start free water flushed 200 q.2 3. Fecal impaction with suspected bowel obstruction. Surgery was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 12 of 18 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 01/12/2024 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 - Minimal harm or potential for actual harm Residents Affected - Some consulted. Treated with enemas and laxatives, improved. 4. Recent respiratory failure .Remains on antibiotic therapy. Further review of the clinical update revealed the following: Special Instructions, dated 12/31/23 at 4:17 PM indicated, .Discharge to SNF: Special Instructions: ok to d/c to SNF; meds per list; resume tube feed diet/aspiration precautions; PT/OT/ST: continue regular bowel regimen; follow up snf pcp; follow up nephrology and GI as per them. Discharge Medications: New medications to start taking Amoxicillin-potassium clavulanate oral tablet 875-125 mg - Take 1 EA orally twice daily; Ipratropium-Albuterol 0.5-2.5 Nebulization solution 0.5-2.5(3) mg/3ml - Take inhalation every 4 hours as needed for shortness of breath. Last dose given: 12/31/23 at 2:00 PM; Mineral Oil Oral - Take 30 ml tube once a day as needed for constipation. Last dose given: 12/31/23 at 3:17 AM .All medications must be taken as directed. Contact your physician before stopping medications. Record Review of Resident #1's Baseline Care Plan, dated 01/04/24, revealed, Resident #1 required one-person physical assist for all ADLs; was to receive Physical and Occupational Therapy; always urinary and bowel incontinent, and had an indwelling catheter; and had a diet order for nothing by mouth, and Jevity 1.5 via his PEG tube. Further review of the care plan did not reveal goals or interventions to address the resident's foley catheter; past history of dehydration and recent diagnosis of severe dehydration; or monitoring/observations related the resident's past history of constipation and recent diagnosis of fecal impaction. Record review of Resident #1's orders, dated as of 01/11/24, did not reveal orders to address the resident's foley catheter; past history of dehydration and recent diagnosis of severe dehydration; or monitoring/observations related the resident's past history of constipation and recent diagnosis of fecal impaction. Further review of Resident #1's electronic health records record revealed, the following orders, dated as of 01/11/24: Order Date: 1/04/24, Mineral Oil Give 30 ml via G-Tube every 24 hours as needed for Bowel Management Order Date: 1/04/24, MiraLax Oral Packet 17 GM (Polyethylene Glycol 3350) Give 1 packet via G-Tube every 24 hours as needed for Bowel Management Order Date: 1/04/24, Fleet Enema Rectal Enema (Sodium Phosphates) Insert 1 applicator rectally every 24 hours as needed for Bowel Management Order Date: 1/04/24, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 3 ml inhale orally every 4 hours as needed for Wheezing Order Date: 1/04/24, *Enteral Feeding Site Care* every night shift for observations Cleanse with Normal saline, pat dry, apply fenestrated dressing daily and as needed. Order Date: 1/05/24, Valproic Acid Oral Solution 250 MG/5ML (Valproate Sodium) Give 5 ml via G-Tube two times a day related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION give 5ml to equal 250mg Order Date: 1/05/24, Amoxicillin-Pot Clavulanate Tablet 875-125 MG Give 1 tablet via G-Tube two times a day for bacterial infection for 7 Days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 13 of 18 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 01/12/2024 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 - Minimal harm or potential for actual harm Order Date: 1/05/24, Docusate Sodium Liquid 50 MG/5ML Give 10 ml by mouth two times a day for Constipation give 10mg to equal 100mg Order Date: 1/05/24, Lexapro Oral Tablet 5 MG (Escitalopram Oxalate) Give 1 tablet via G-Tube one time a day related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED Residents Affected - Some Order Date: 1/09/24, NPO (Nothing by Mouth) diet NPO texture, NPO consistency Order Date: 1/09/24, *Enteral Order*- Monitor resident for signs/symptoms of misplacement of enteral tube: Difficulty with medication/feeding/water Order Date: 1/10/24, License nurse to monitor: *ABDOMINAL WOUND* for any abnormalities or changes to surrounding skin for s/s of infection, pain associated with site. Document plus (+) sign for no observed changes and a minus (-) sign for any observed changes, notify MD, and document findings in a progress note. every shift for observations. In an interview with CNA A on 01/11/24 at 2:32 PM, she said she worked at the facility for about two years and mainly worked on Resident #1's hall during the 2:00 PM to 10:00 PM shift. She said sometimes she was assigned to work other halls. CNA A said she assisted residents with hygiene, incontinence care, and if they wanted water, she provided it. CNA A said Resident #1 did not talk, had a feeding tube, was bedbound and required total assistance. She said he only got fed through his feeding tube. CNA A said the resident required a lot of lip care due to g-tube feeding. She said she felt like the position of his mouth, due to metal plates put in after a car accident, was also why the resident's lip could have been dry and why he needed a lot of oral care. She said no changes had been made to the care Resident #1 received since he returned from the hospital. CNA A said the only difference was now the resident has a catheter. She said Resident #1 had issues with constipation in the past but did not recall when. She said even though he had issues with constipation, Resident #1 experienced way more issues with diarrhea. CNA A said she could not remember the last time the resident was constipated. CNA A said she got all the information she needed about her residents by accessing their electronic health records. She said she can find out things like the level of assistance residents required and the type of diet they were on in the electronic health record. CNA A said if a resident's bowel movements needed to be monitored, the nurses would let the CNA's know. She said Resident #1's bowel movements were documented by CNA's in his electronic health record. CNA A said the form asked for details like diarrhea, constipated, soft, small, medium large. She said the same form also had a place to complete when residents did not have bowel movements. She said she did not know if the nurses reviewed bowel movements documented in Resident #1's electronic health record. CNA A said she was not sure of the exact number of days a resident could go without having a bowel movement. She said if she noticed a resident did not have a bowel movement after 48 hours, she would let the nurse know. CNA A said she would notify a nurse about a possible issue with Resident #1's catheter if she noticed a different color urine, blood in his brief, or if she noticed a scratch or swelling and redness. In an interview with Med Aide A on 01/11/24 at 2:55 PM, she said she worked at the facility for a little over two years. She said she was a Med Aide but picked up extra shifts filling in as a CNA. Med Aide A said she was working as a CNA today. She said she was familiar with Resident #1 and had provided care to him as a CNA several times before he went to the hospital. Med Aide A said she had also cared for the resident since he was readmitted a few days ago. She said Resident #1 was a total care resident and needed help with everything. She said the resident was on a PEG tube and had a foley catheter now. Med Aide A said he did not talk, and she never knew the resident to be constipated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 14 of 18 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 01/12/2024 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 She said the resident's bowel movements were always pretty putty like. Level of Harm - Minimal harm or potential for actual harm In an interview with LVN B on 01/11/24 at 4:52 PM, she said she worked at the facility for about 3 years and had worked all over the facility at different times. She said when she was assigned to her regular hall, she was the nurse responsible for providing care to Resident #1. She said Resident #1 was nonverbal, was good as long as he was kept dry and had a PEG tube. She said Resident #1 did not have a history of constipation, nor did he have a history of dehydration. LVN B said he did not have a history of dehydration because he received nutrition and fluids through his feeding tube. LVN B said she could not recall the last time she reviewed Resident #1's care plan. She said she did not know who responsible for reviewing or updating a resident's care plan. She said she imagined it was the charge nurse or the DON's responsibility. She said she provided care to residents, based on the orders in the electronic health record. LVN B said she received updates on resident changes during report from nurses during shift change. LVN B said she was aware Resident #1 had been in the hospital and returned to the facility a few days ago. LVN B said she heard Resident #1 was hospitalized for an abscess, but LVN A was not sure who told her about the abscess. She said she was not aware Resident #1 was diagnosed with severe hydration and fecal impaction. LVN B said Resident #1's recent diagnoses would not have changed the care the resident was currently receiving because it was standard to monitor Resident #1 for signs and symptoms of dehydration and constipation related to his PEG-tube. She said Resident #1 did not have a catheter before he went to the hospital but did have one in place now. She said the resident had orders in place for his catheter but did not know what diagnosis resulted in the catheter. She said now that Resident #1 had a catheter, it made it easier to track his urinary output. She said bowel movements and urinary output was documented in Resident #1's electronic health record by CNA's. She said she did not know who was responsible for reviewing Resident #1's bowel movements or urinary output. She said the CNA's were very good about verbally communicating with the nurses about issues with the residents. She said the CNA's were aware they were to notify a nurse when a resident went 48 hours without a bowel movement. She said she was not aware Resident #1 ever had orders for nurses to monitor his bowel movements. She said she had not reviewed Resident #1's bowel and bladder elimination records before, or since he had returned from the hospital. She said she was responsible for making sure residents with PEG-tubes did not aspirate and checked for residual air to make sure their stomachs were not full. LVN B said she performed those tasks for every resident that had a g-tube before LVN B administered every medication dose. She said all this information was documented on the resident's MAR. She said when completing the MAR for a resident with a PEG-tube, certain yes/no questions like did you assess bowel sounds, and did you assess lung sounds, were triggered and had to be answered before being allowed to move forward on the MAR. LVN B said if a resident went a full 8 hour shift without urinating, she would complete an assessment on the resident and notify the resident's MD. She said if a resident went two days without a bowel movement, they would also need to be assessed. LVN B said she would check for bowel distention and then contact the doctor to see if a catheter needed to be put in, or if x-rays needed to be ordered for the resident. She said she would check the resident's vital signs and ask the resident how much they had to eat or drink. She said she would also check with the CNA's and ask about their consumption. LVN B said all this information would be documented in a progress note or a change of condition in the resident's electronic health record. She said there was no distinction between a progress note and completing a change in condition assessment in a resident's electronic health record. She said completing a change in condition assessment in the electronic health record also triggered a progress note to appear with the change of condition information. She said she would notify the DON, the doctor and the family or Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 15 of 18 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 01/12/2024 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 - Minimal harm or potential for actual harm Residents Affected - Some responsible party. All this information should be documented in a progress note. LVN B said she checked if a tube feeding was not flowing freely; if LVN B could not hear placement of the tube; observed a distended abdomen; and, if the skin and site of the tube, itself appeared unhealthy. She said any of those scenarios with a resident who received tube feedings would be things to document on a change of condition assessment, notify the MD, family, and DON. She said if a resident was aspirating, she would contact emergency services and then make the necessary notifications. She said failure to document, assess or review Resident #1's changes in both urinary and bowel output put the resident at risk of bladder eruption, bowel obstruction, and pain and discomfort at the very least. She said information about residents like this and signs and symptoms to look out for were verbally discussed all throughout the shift with the necessary staff and during shift change. She said she would instruct CNA's to be mindful of the color, amount, or any odor related to urinary output. She said the CNA's knew to report issues like this to the nurse immediately. She said the CNAs know they could also report to the DON. She said all nurses could assist in the care of any resident and had access to review and document on any resident's electronic health record. In an interview with the DON on 01/11/24 at 7:41 PM, she said she worked at the facility since the week of Thanksgiving 2023. She said Resident #1 returned to the facility from the hospital on either 01/04/24 or 01/05/24. She said she could not recall off the top of her head Resident #1's medical history, or his recent diagnoses from the hospital. She said there were no changes or updates made to the care Resident #1 was receiving from staff. She said she was aware Resident #1 was readmitted to the facility with a foley catheter in place. She said she could not recall off the top of her head what diagnosis Resident #1 had been given for the insertion of the catheter. She said she would have to look at the resident's chart. She said she was waiting on an order from Resident #1's doctor to d/c his foley catheter. She said the nurses on duty at the time residents returned to the facility were responsible for completing readmission assessments and developing baseline care plans. She said she did not know who completed either when Resident #1 returned to the facility. She said she reviewed the resident's readmission assessment and baseline care plan but could not recall specifics of either. She said the only thing she remembered was Resident #1's readmission assessment did not include the resident's foley catheter. She said the resident's baseline care plan did include Resident #1's catheter. She said could not recall the staff that completed the readmission assessment or the baseline care plan. She said she addressed the error on the readmission assessment with the staff to be corrected but did not document anything specific on the error or the conversation she had with the staff. She said other than the placement of the catheter, nothing had changed in the care and treatment Resident #1 was receiving since being readmitted to the facility. She said the facility was still within their timeframe for completing Resident #1's assessments and finalizing his care plan since being readmitted . She said she did not know off the top of her head what the facility's policy was on assessments or care plans, but that was what the facility was following. She said the ADON was typically responsible for reviewing readmission assessments and baseline care plans. She said the ADON's last day was 01/02/24, so ultimately, it was her responsibility to review assessments and care plans. She said she did not see an issue with Resident #1's baseline care plan not explicitly including his recent diagnoses of severe dehydration and bowel impaction because these are all things still being monitored by the staff. She said urinary output and bowel movements were being monitored for the resident. She said the only major change for Resident #1 was that he returned with a catheter and reiterated that nothing had changed in the care he was currently receiving. She said she did not know Resident #1 had a documented history of dehydration and constipation. She said she did not know prior to going to the hospital, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 16 of 18 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 01/12/2024 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 - Minimal harm or potential for actual harm Residents Affected - Some Resident #1 was care planned for IV hydration therapy and for nurses to monitor his bowel movements. She said Resident #1's recent diagnoses of impaction and severe dehydration should have been care planned. She said the resident was put at risk of further impaction if his bowel movements were not appropriately monitored. She said Resident #1 was also at risk for constipation, impaction, and Sepsis by not having his recent impaction care planned. She said the resident was at risk of further dehydration by not having his recent severe dehydration diagnosis care planned. An observation of Resident #1 on 01/11/24 at 6:28 PM revealed the following: The resident wore a gown that tied at the back of his neck. His face was clean in appearance, his lips were slightly chapped. The resident curled his body into a slight fetal position as LVN A removed the sheet that covered his body and raised his gown and exposed the resident's abdomen. He wore what appeared to be gown that tied at the back of his neck. He was clean in appearance; his lips were slightly chapped, and the resident wore a brief underneath the gown. Resident #1's PEG-tube sight was clean and appeared to be operating appropriately. LVN A pulled the resident's gown down and placed the sheet back over his body. Plastic tubing containing what appeared to be urine, could be seen on the lower left side of the resident's bed after the sheet was placed back. In an interview with LVN A on 01/11/24 at 6:28 PM, she said she had worked for the facility for a few months and was typically the nurse on Resident #1's hall during the 6:00 PM to 6:00 AM shift, unless she was assigned to work a different hall. She said even though the resident was nonverbal, he still communicated with LVN A in his own way. LVN A said when she did her first round on Resident #1, she always asked him if he was doing okay, and he would usually give her a thumbs up. She said she had heard mention of the resident whispering words, but she never observed it for herself. LVN A said the resident had returned from the hospital a few days ago and had not fully returned to behaving like himself. She said the resident seemed as if he had even more of a cognitive decline since going to the hospital. LVN A said nothing had changed nor had she been made aware of changes or updates to the care or treatment for Resident #1. She said the resident was readmitted to the facility with a foley catheter in place. LVN A said she was not sure what diagnosis the resident returned with to have a catheter. She said she did not know whether Resident #1 had orders or care planned interventions for the foley catheter. She said it was standard for all residents with catheters to have their urinary intake and output monitored. LVN A said CNA's were responsible for documenting both urinary and bowel movements in the resident's electronic health record. She said the only time she would monitor or assess the resident for issues with the catheter or bowel movements, was if during her interaction with the resident, she noticed a problem or if a CNA notified her of an issue. She said the CNA's were very good about notifying the nurses of resident issues. LVN A said all the CNA's knew if a resident went longer than 3 days without having a bowel movement that a nurse needed to be notified. She said she did not specifically review the resident's Urinary and Bowel Elimination Record because that was something the CNA's documented. LVN A said as far as she knew, Resident #1 did not have a history of dehydration because he received fluids and nutrition via his PEG-tube. She said she did not know Resident #1 to have a history of constipation either. LVN A said she did not know Resident #1 was treated for severe dehydration or fecal impaction during his recent hospital stay. LVN A said the only update she received on Resident #1 when he returned to the facility, was report from the nurse she relieved the next time she cared for Resident #1 after he was readmitted . LVN A said she was the nurse in charge of Resident #1's care when he was sent out to the hospital in December. She said she never observed Resident #1 exhibiting signs or symptoms of dehydration, constipation, or fecal impaction. She said if the resident was impacted, he would have had a distended stomach and likely expressed discomfort. She said she was never notified of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 17 of 18 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 01/12/2024 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 - Minimal harm or potential for actual harm any constipation issues either. LVN A said listening for bowel sounds was part of providing treatment to Resident #1 via PEG-tube before he went to the hospital. She said if she had noticed signs or symptoms of constipation or a distended stomach, she would have performed an assessment, completed an SBAR in the resident's electronic health record, notified the MD and followed any orders or directives, and notified the DON. Residents Affected - Some In an interview with the DON on 01/12/24 at 11:10 AM, she said the third row of Resident #1's December 2023 Bowel and Bladder Elimination Record was not necessary for CNA's to complete, unless the resident had experienced additional urinary output or bowel movement after the initial one documented during a shift. She said the blank spaces that appeared within the first two rows of both the bowel and FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455582 If continuation sheet Page 18 of 18