Health inspection·May 30, 2025

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain grooming and personal care for 3 (Resident #32 Resident #19 and Resident #16) of 12 residents reviewed for ADL care, in that: Residents Affected - Some The facility failed to ensure Resident #32 was provided personal grooming (dry patches and flaky skin) by facility staff on 5/28/2025. Resident #19 was not provided nail care. Resident #19's nails were long past the tips of his fingers with a dark substance on top and underneath his nail tips on 5/28/2025. Resident #16 was not provided nail care. Resident #16's nails were long past the tips of her fingers with a dark substance underneath and dried substance on top the nails on 5/28/2025. This failure placed residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings included: Resident #32 Record review of Resident #32's face sheet dated 5/29/2025 revealed a [AGE] year-old male was admitted to the facility on [DATE]. Resident #32 had diagnoses included: Gastroenteritis and colitis (inflammation of the digestive tract), hemiplegia (weakness of one side of the body) and hemiparesis (one-sided weakness or inability to move) following cerebral infarction (blood vessel blockage in the brain) affecting left non dominant side, anxiety disorder, and glaucoma (damage the optic nerve). Record review of Resident #32's non-descript MDS assessment dated [DATE] revealed Resident BIMS score was 15 which indicated he was cognitively intact. Resident #32 depended on staff with ADL assistance with one staff for partial/moderate assistance. Record review of Resident #32's care plan revised on 1/10/2025 revealed Resident #32 had ADL Page 1 of 9 455582 455582 05/30/2025 Paradigm at Bay City 1800 13th St Bay City, TX 77414

F 0677 Level of Harm - Minimal harm or potential for actual harm self-care performance deficit and was at risk for further decline in ADL functioning and injury d/t functional impairments. Interventions: provide extensive assistance of 1 staff hygiene/grooming. Record review of Resident #32's personal hygiene history from POC dated 5/16/2025 - 5/29/2025 revealed the following was completed: Residents Affected - Some Personal hygiene: The ability to maintain personal hygiene, including coming hair, shaving .washing/drying face and hands . Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity. Record review of partially completed resident shower sheets undated revealed it was unable to determine who provided the personal hygiene (grooming, shaving, nail care) to the residents. During an observation on 5/28/2025 at 10:25 a.m., Resident #32 had dry patches and flaky skin on his forehead and sides of his face without facial hair. Also observed was a full beard (facial hair was approximately 1 ½ inches). During an observation and interview on 5/25/2025 at 12:42 a.m., Resident #32 said his face had not been washed that morning and he did not like his facial hair. He said he was not able to open the twist-off top on the toothpaste because of his paralysis. He said he had not told the staff he needed to be shaved and the staff had not asked if he needed assistance. He said he never liked facial hair. He said his face was itchy with the facial hair and he said, I can't stand it. Resident #32 had dried patches and flaky skin on his forehead and sides of his face without facial hair. Resident #32 had an unkept beard (2-3 inches - full beard). RESIDENT #19 Record review of Resident #19's face sheet dated 5/29/2025 revealed a [AGE] year-old male admitted to the facility originally on 10/15/2021 and current admission was on 2/15/2025. Resident diagnoses included: malignant neoplasm of prostate (prostate cancer), COPD (lung disease), heart failure, and mild cognitive impairment, Record review of Resident #19's quarterly MDS dated [DATE] reflected a BIMS score of 15 indicating that resident was cognitively intact. Further review section GG Functional Abilities reflected that resident required partial/moderate assistance from staff with showers. Record review of Resident #19's Comprehensive Care Plan date last reviewed 3/27/2025 reflected Resident #19 reflected the following: ADL self-care performance deficit: Resident #19 has ADL self care deficits and is a risk for further decline in ADL functioning and injury .Interventions: Anticipate needs - provide prompt assistance .Provide supervision assistance of 1 staff for personal hygiene/grooming . Observation and interview on 03/05/25 at 10:10 a.m. revealed Resident #19 in his room and his nails were long past the tips of her fingers with a dark substance underneath and on top the nails on both hands. Resident #19 said it had been a while since his nails were trimmed. He said he had not been offered to clean his hands. He said he was not sure why they were dirty. 455582 Page 2 of 9 455582 05/30/2025 Paradigm at Bay City 1800 13th St Bay City, TX 77414

F 0677 Level of Harm - Minimal harm or potential for actual harm Observation and interview on 3/28/2024 at 12:10 p.m. revealed Resident #19 went to the dining room. He was sitting and breaking up saltine crackers into his bowl of chili. He continued to have the same dark substance underneath his nails and dried substance on top. Resident #19 said the staff did not offer him to wash or sanitize his hands before he ate. Residents Affected - Some Resident #16 Record review of Resident #16's face sheet dated 5/29/2025 revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident diagnoses included: Type 2 diabetes mellitus with diabetic neuropathy (nerve damage caused by high blood sugar levels), major depressive disorder, post-viral fatigue syndrome, and generalized anxiety disorder. Record review of Resident #16's quarterly MDS dated [DATE] reflected a BIMS score of 99 indicating the resident could not complete the interview. Further review section GG Functional Abilities reflected that resident required partial/moderate assistance from staff with personal hygiene. Record review of Resident #16's Comprehensive Care Plan date last revised 5/14/2025 reflected Resident #16 reflected the following: ADL self-care performance deficit: Resident #16 has ADL self care deficits and is a risk for further decline in ADL functioning and injury .Interventions: Anticipate needs - provide prompt assistance .Provide extensive assistance of 1 staff for hygiene/grooming . Observation and interview on 5/28/2025 at 12:17 p.m. revealed Resident #16 was eating her food in her room. She was feeding herself and her fingernails were long past her tip. She was trying to grip the fork and it was slipping from her grip held by the fingernail tips. Resident #16 said she would like her fingernails to be trimmed down. She said the nails made it difficult to eat. Interview on 5/28/2025 at 12:58 p.m., LVN A said Resident #32 should be shaved during morning care or during his bath. She said a residents' face should be washed in the morning. She looked at Resident #32 and said his face had dry flaky skin and his beard was scruffy (not trimmed and overgrown). She said CNAs were responsible for shaving resident faces and cleaning residents' faces. She said Resident #32 could had suffered discomfort and skin irritation. LVN A said staff should shave residents upon request or ask residents if they wanted to be shaved. LVN A said we (staff) had to catch [Resident #19] in a good mood for him to accept nail care. She said she was not sure if he was offered nail care or if his hands had been washed. She said his hands should have been washed or sanitized before he ate his food to prevent cross-contamination. LVN A said nail care should have been offered to Resident #16. LVN A said Resident #16's nails were dirty underneath and the nails needed to be trimmed down. She said the resident's overgrown and dirty nails could have led to infection and the length could have been a barrier from Resident #16 holding her fork properly. She said CNAs and Nurses were responsible for nail care and ensuring resident's nails and hands were clean. She said the CNAs for the hall were currently on break. She said Resident #16's nails should have been cleaned before she ate to prevent cross-contamination. Interview on 5/28/2025 at 1:30 p.m., the DON said the resident's nails should have been cleaned daily or as needed. The DON said resident should be shaved upon request or offered during showers to provide dignity. She said CNAs should have documented on the shower sheets or in the POC. She said the shower sheets did not have dates and some did not have CNA names, so it could not be determined who assisted residents with grooming/personal hygiene. She said resident hands and nails should be 455582 Page 3 of 9 455582 05/30/2025 Paradigm at Bay City 1800 13th St Bay City, TX 77414

F 0677 cleaned and trimmed on shower days and cleaned or sanitized before meals. The DON said the nurses were supposed to make sure that the CNAs assisted residents with grooming and personal hygiene. Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy on AM Care (revised 6/2019) revealed the following: Residents Affected - Some Policy: It is the policy of this facility that the nursing staff will assist the resident with their hygiene and self-care needs to prepare resident for morning activities and to observe resident's general condition . 17. Give resident moist cloth and towel for cleaning hands and face, assisting if necessary. Record review of the facility policy on Shaving (revised 6/2019) revealed the following: Subject: Shaving Policy: It is the policy of this facility that the facility staff will assist the residents with shaving to maintain appearance and self-esteem . Record review of the facility policy on Nail Care (not dated) revealed the following: Subject: Nail Care Policy: It is the policy of this facility that the facility staff will assist the residents with nail care as needed. Residents who are unable to care for their own finger or toe-nails require staff assistance in keeping nails clean and trimmed. Procedure: Before staff cares for any resident's nails, check with the nurse to be sure that cutting nails is within the scope of duties for a nurse's aide . (Note: Before you begin nail care, staff wash their hands and put gloves on. Ensure equipment such as scissors or trimmers are clean to prevent passing on infection Proper nail care can reduce the transmission of disease because the hands and feet are often exposed to many microorganisms which can grow quickly in the nail beds. This procedure will also help the patient to remain comfortable and allow facility staff to look for signs of infection that can lead to complications .) 455582 Page 4 of 9 455582 05/30/2025 Paradigm at Bay City 1800 13th St Bay City, TX 77414

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interviews, and record reviews the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 1 medication storage rooms and 1 of 1 supply closets, reviewed for drug labeling and storage, in that: The Medication Storage room had an inhaler that was open and in use, with no open date. It also had a TB vaccine vial and a Hepatitis B vaccine vial that was open with no opening date. The Medication Supply closet had 4 expired bottles of liquid iron. These failures place residents at risk for receiving biologicals and medications which are ineffective and/or not safe. Findings included: In an observation and interview on 5/29/25 at 1:00pm with LVN A, an inhaler was found in the Medication Storage room behind the nurse's station, that did not have an open date on it. There was also a TB vaccine vial and a Hepatitis B vaccine vial found in the mini fridge that were open but did not have an open date on them. LVN A said the inhaler would not be as effective if it was old. She said the ADON handled the vaccines. In an interview with the ADON on 5/29/25 at 1:30pm, she said she was the one who gave the vaccines to new employees. She said she had not given any vaccines recently and did not know why the tops were removed from the TB and Hepatitis vials. She said she would have to throw them away because she did not know when they were opened and if they were still effective. In an observation and interview on 5/29/25 at 1:45pm with LVN A, 4 bottles of liquid iron were found in the Medication Supply closet by the front entrance. LVN A said there was a supply person who stocked the room, and she was the one who kept up with the expiration dates on the meds. She said expired medications would not be as effective. In an interview with the DON on 5/29/25 at 2:05pm, she said she expected staff to write the open date on any medication as soon as they opened it. She said an inhaler was good for 30 days after it was opened and then it would be less effective after that. The DON said the vaccines would be less effective if they were opened for longer than they should have been and there was no way of knowing since there was no open date on the bottle. She said the Supply closet (by the entrance) was run by a supply person, and she had not been trained yet on how to look for the expired meds, and it was her 455582 Page 5 of 9 455582 05/30/2025 Paradigm at Bay City 1800 13th St Bay City, TX 77414

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some fault for not training her yet. She said she expected staff to check the med carts daily for expired medications since they worked with them all the time, but she did a check of all the carts once a month. Record review of the facility's policy and procedure on Storage of Medications (Revised August 2020) read in part: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists .Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmics [eye drops], nitroglycerin tablets [for chest pain], and blood sugar testing solutions and strips require an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency .When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and record the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days from opening, unless the manufacturer recommends another date or regulations/guidelines require different dating .All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining . 455582 Page 6 of 9 455582 05/30/2025 Paradigm at Bay City 1800 13th St Bay City, TX 77414

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 5 residents (Resident #30) reviewed for infection control, in that: Residents Affected - Few LVN A failed to wear PPE for EBP, when giving Resident #30 his g-tube (tube into stomach for nutrition) medications. This deficient practice could place residents at-risk for infection due to improper care practices. Findings included: Record review of Resident #30's undated face sheet revealed he was a [AGE] year-old male with an admission date of 4/26/22, and a readmission date of 1/12/24. He had diagnoses which included: fracture of the right humerus (fracture of the right upper arm), hemoperitoneum (bleeding in the abdomen), aphonia (unable to speak due to damage to the voice box), aphasia (unable to process language), traumatic brain injury, and foreign body in respiratory tract causing asphyxiation (suffocation). Record review of Resident #30's annual MDS assessment, dated 1/1/2025, revealed a BIMS score could not be completed due to his medical condition. The MDS revealed he had severely impaired cognitive skills for daily decision making. The resident was dependent on staff with all ADLs. According to the MDS, the resident was using a feeding tube for all of his nutritional and fluid intake. Record review of Resident #30's care plan dated 5/11/25 had a Focus: The resident was receiving total nutrition/hydration through his feeding tube (Initiated: 8/4/23). The goal was to remain nourished and without aspiration (getting into the lungs) or dehydration (Initiated: 8/4/23, Revised: 5/11/25, Target: 8/11/25). Interventions included assessing the abdomen prior to feeding/flushing, checking placement of the tube, giving all feedings/water flushes via the feeding tube, and keeping his head of bed elevated at least 30 degrees. Focus: The resident required EBP's d/t his PEG tube (Initiated: 4/2/24). The goal was to not have any adverse effects r/t EBP's (Initiated: 4/30/24, Revised: 5/11/25, Target: 8/11/25). Interventions included PPE: gown/gloves during high contact resident care like dressing, bathing/showering, transferring, providing hygiene, changing briefs, assisting with toileting, device care, and wound care. Record review of Resident #30's Physician Orders revealed the following orders from MD L: Enhanced Barrier Precautions (EBP): PPE Required- Hand hygiene, Gown, Gloves. Ordered on 4/2/24 at 10:30am. 455582 Page 7 of 9 455582 05/30/2025 Paradigm at Bay City 1800 13th St Bay City, TX 77414

F 0880 - Level of Harm - Minimal harm or potential for actual harm Enteral Feeding- Order Jevity 1.5 (type of feeding) @ (60ml/hr) with (40ml/hr) free water flush via G-tube continuously x 22 hours. Ordered on 1/23/25 at 9:06pm. Residents Affected - Few Wound Care Abdominal Abrasion- Cleanse with Dakins (type of wound cleanser) and apply Mupirocin (antibiotic) and Calcium Alginate (wound dressing) and cover with dry dressing, every day. Ordered on 4/28/25 at 9:39am. Record review of Resident #30's Progress Note from 5/19/25 by NP O revealed the resident had an abdominal wound and a g-tube due to dysphagia (trouble swallowing). Record review of Resident #30's Wound Care note from 5/28/25 by NP B, revealed he had a midline, abdominal, surgical wound that was 6.4cm x 0.55cm x 0.2cm. The wound was acquired on 12/10/24 and was being treated by the Wound Care team. In an observation and interview on 5/29/25 at 10:00am, Resident #30 was observed lying in bed with his tube feeding running. LVN A paused the resident's feeding and gave him his morning medications through his g-tube. LVN A was wearing gloves but was not wearing a gown when she gave the resident his medications. She said EBP was like standard precautions which meant every resident was the same and they only wore gloves with them. LVN A said she had only been working at the facility for 2 weeks and had come from the hospital setting where they did not use EBP. She said she was going to find out for sure what EBP meant and get back with the Surveyor. In an interview on 5/29/25 at 10:17am, LVN A said EBP was for any resident that had a g-tube, foley (tube into bladder to drain urine), or open wound. She said she had to wear a gown and gloves for close contact, like giving g-tube meds and it was to prevent infection. In an interview with the DON on 5/29/25 at 2:00pm, she said EBP was for any resident with open wounds, IVs, foleys, or g-tubes. She said a gown and gloves should be worn when providing care. She said she expected staff to wear the proper PPE with every resident who was on EBP, and LVN A should have worn the PPE while she gave the g-tube meds to Resident #30. She said the EBP was to protect the residents and the staff from infection. Record review of the facility's policy and procedure on Enhanced Barrier Precautions (Revised March 2024) read in part: Enhanced Barrier Precautions is an infection control intervention designed to reduce the transmission of multidrug-resistant organisms [MDROs] and employs targeted gown and glove use during high-contact resident care activities for targeted residents. Enhanced Barrier Precautions (EBP) are used in conjunction with standard precautions and expands the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following: .Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO .Examples of indwelling medical devices: central lines [flexible tube inserted into a large vein], urinary catheters, feeding tubes, and tracheostomies [opening into the windpipe for an 455582 Page 8 of 9 455582 05/30/2025 Paradigm at Bay City 1800 13th St Bay City, TX 77414

F 0880 Level of Harm - Minimal harm or potential for actual harm airway] .When EBP are indicated, EBP should be employed for the following high-contact resident care activities: Dressing, bathing/showering, transferring, providing hygiene, changing briefs, assisting with toileting, device care, and wound care . Residents Affected - Few 455582 Page 9 of 9