Health inspection·April 26, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few fracture was corrected with surgery and notified administrator. The nurse reading chart saw documentation that the resident was sent to a local hospital for a brain bleed . The incident occurred on 03/12/23 at 7:18 p.m. and was reported to the state agency on 03/17/23. The investigation findings were confirmed occured by the facility. Record review of a care plan updated on 03/26/23 indicated Resident #101 had a fall on 3/12/23 and required hip surgery and had a hematoma (a pool of mostly clotted blood that forms in an organ, tissue, or body space) to forehead. During an observation and interview on 04/25/23 at 2:03 p.m., Resident #101 was sitting in her wheelchair. Resident #101 said she fell and broke her hip and hurt her head. She said she remembered she stood up but could not remember anything else. During an interview on 04/25/23 at 2:09 p.m., Resident #101's roommate said said she witnessed Resident #101 fall. She said Resident #101 was waiting to be put to bed and just stood up reaching for her gown on the bed and fell backwards landing with her head under the roomates bed. The roomate said she yelled for help and the nurses ran in to care for Resident #101. During an interview on 04/26/23 at 12:19 p.m., RN B said on 3/12/23 she gave report to LVN C and was about to clock out when Resident #101 fell. She did not witness the fall; she heard the roommate yelling. She said LVN C assessed Resident #101 and sent her to the hospital. RN B said on 3/13/23 she notified the DON of Resident's #101's brain bleed after a phone call with the hospital. She said it was not discussed if this incident was reportable. RN B said she knew it was a reportable incident. During an interview on 04/26/23 at 5:31 p.m., LVN C said she was responsible for Resident #101 at the time of the fall. She said she found the resident on the floor after hearing the roommate yelling. She said she assessed the resident, and stayed with her until the ambulance picked her up. LVN C said she called the hospital later that night and was informed Resident #101 had a brain bleed and was being transferred to another hospital. She said she did not notify the DON, LVN D notifed the on-call staff and DON for her while she was caring for a resident. During an interview on 04/26/23 at 1:30 p.m., LVN D said on 03/12/23 Resident #101 was found on the floor. She said she started the documentation, called the ambulance, physician, and family, on call staff and DON. She said on 03/12/23 she called the hospital for an update and was informed Resident #101 had a cerebral cranial bleed and was sent to a different hospital. She said she notified the on-call manager, who was the UM about Resident #101's brain bleed. During an interview on 04/26/23 at 2:40 p.m., the UM said she was on call on 03/12/23. She said LVN C and LVN D notified her of Resident #101's fall and at about 10:00 p.m., that night LVN D notified her of Resident #101, moving to another hospital due to a brain bleed. The UM said she did not know at that time a brain bleed was a reportable incident. She said she was responsible for not notifying the DON of the brain bleed. The UM said she knew to notify the DON about a fracture but was unsure to notify about a brain bleed before the incident. The UM said looking back she should have been reported the brain bleed to the DON. The UM said not reporting timely was not following facility policy of reporting incidents. During an interview on 4/26/23 at 11:22 p.m., the DON said on 3/12/23 LVN D notified her Resident #101 fell and was sent to the hospital. She said on 3/15/23, RN B notified her Resident #101 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455594 If continuation sheet Page 2 of 3 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 455594 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Kountze 604 Fm 1293 Kountze, TX 77625 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few diagnosed with a brain bleed while Resident #101 was still in the hospital. The DON said she called corporate on 3/15/23 and a left message asking whether to report the resident's brain bleed or not. The DON said she spoke with the Administrator on 3/16/23 in the evening, and the Administrator told her she thought the incident involving Resident #101 was reportable but to call the corporate nurse. She said the corporate nurse was unsure if the incident was reportable and she would check if it was reportable. The DON said on 3/17/23 about 8:30 a.m., they began the investigation. She said the investigation was completed and called in to HHSC. The DON said she should have called the corporate nurse back and if no answer, she should have reached further up. The DON said the Administrator was responsible for reporting incidents and if the Administrator was not there, she was responsible for reporting. The DON said the Administrator usually walked her through the reporting and if the Administrator was not there the corporate nurse would help her. She said before this incident she was not fully educated on what was reportable and what was not. The DON said it should have been reported between 2 and 24 hours from the time the incident was reported. The DON said the risks of incidents not being reported timely were similar incidents happening again, missed something that could cause resident more harm, and not following policy with late reporting. During an interview on 4/26/23 at 12:04 p.m., the Administrator said she was responsible for reporting timely within 2 to 24 hours depending on the circumstances and when she was not there, the DON was responsible. The Administrator said the DON was always able to reach out to their regional/ corporate nurse for assistance. She said herself and the DON had both been educated on reporting timely and what was reportable. The Administrator said she left the country from 3/7/23 until 3/15/23. The Administrator said she learned of Resident #101's injury on 3/17/23 when the nurse received report from the hospital. She said the incident should have been reported before she came back. The Administrator notified corporate the incident was reported late, completed an investigation, and reported to HHSC. She said a full audit of recent admissions was completed. The administrator said her expectation was all incidents reported timely and continued education of staff routinely on reportable events. Record review of the facility policy titled, ABUSE/NEGLECT, revised 6/2019, indicated, . 2. The Facility shall report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures. All allegations and /or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's Designee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455594 If continuation sheet Page 3 of 3