Health inspection·June 14, 2023

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 5gm, B Complex-(water soluble vitamins) {Thiamine 200mg, Riboflavin 4mg, Niacin 200 mg, Pyridoxine 4mg} B5 250mg Methylcobalamin (B-12), Magnesium Chloride (mineral supplements) 1000mg, Calcium 200mg, Zinc 10mg, Glutamine 150 mg, Arginine 500 mg Ornithine 150mg, Lysine 250mg, Citrulline250mg-BCAA 2 mls. Record review of a MAR dated April 2023 indicated Resident #1 received the cognitive IV infusion on 04/05/23 at 9:09 a.m. by Contract IV RN. Record review of Nursing Note dated 04/05/23 at 12:00 pm for Resident #1 indicated the following: .VS 133/79 97.3 80 17 [redacted] INFUSION NOTE: Resident has been cleared for IV nutrient therapy by the Facility Physician. Current meds were reviewed, if any, and all contraindications have been found. Reviewed resident allergies. Order verified. Assessment completed. Resident prepared for IV vitamin infusion. Site prepared per protocol 22 g LH x2 attempts. IV site secured per protocol no redness or signs of infiltration. Infusion for wellness r/t multiple comorbidities, promote skin/tissue health, and promote the immune system. Order: 0.9% Normal Saline 250 ml, [redacted] Nutrition Protocol Infusion started at 250 ml/hr on dial a flow. Patient in no distress, IV site without redness, edema, signs of infiltration. Patient comfortable and denies needs. 1300 Infusion complete. Resident tolerated infusion without difficulty or complication. IV dc ' d gauze and Coban to site. Report of infusion complete. Indicated as entered by Contract IV RN. Record review of a Post IV Infusion Evaluation dated 04/05/23 indicated Resident #1 had no adverse reactions noted during the nutrition infusion or 4 hours later. There were no other post evaluations documented by facility staff after the dates of the infusions for Resident #1. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #1 received IV therapy while being a resident of this facility and within the last 14 days. Record review of the physician ' s orders dated May 2023 for Resident #1 included orders for Nutrition Infusion IV -ONE TIME- 250ml 0.9% NS normal saline @250ML/HR Vitamin C (water soluble vitamin) 5gm, B Complex-(water soluble vitamins) {Thiamine 200mg, Riboflavin 4mg, Niacin 200 mg, Pyridoxine 4mg} B5 250mg Methylcobalamin (B-12), Magnesium Chloride (mineral supplements) 1000mg, Calcium 200mg, Zinc 10mg, Glutamine 150 mg, Arginine 500 mg Ornithine 150mg, Lysine 250mg, Citrulline250mg-BCAA 2 mls. Record review of a MAR dated May 2023 indicated Resident #1 received the cognitive infusion on 05/02/23 at 9:09 a.m. by Contract IV RN. Record review of Nursing Note dated 05/02/23 at 12:00 for Resident #1 indicated the following: .VS 131/95 97.4 96 18 [redacted] INFUSION NOTE: Resident has been cleared for IV nutrient therapy by the Facility Physician. Current meds were reviewed, if any, and all contraindications have been found. Reviewed resident allergies. Order verified. Assessment completed. Resident prepared for IV vitamin infusion. Site prepared per protocol 22 g LH x2 attempts. IV site secured per protocol no redness or signs of infiltration. Infusion for wellness r/t multiple comorbidities, promote skin/tissue health, and promote the immune system. Order: 0.9% Normal Saline 250 ml, [redacted] Nutrition Protocol Infusion started at 250 ml/hr on dial a flow. Patient in no distress, IV site without redness, edema, signs of infiltration. Patient comfortable and denies needs. 1300 Infusion complete. Resident tolerated infusion without difficulty or complication. IV dc ' d gauze and Coban to site. Report of infusion complete. Indicated as entered by Contract IV RN. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455594 If continuation sheet Page 2 of 13 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 06/14/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of a Post IV Infusion Evaluation dated 05/02/23 indicated Resident #1 had no adverse reactions noted during the nutrition infusion or 4 hours later. There were no other post evaluations after the dates of the infusions for Resident #1. Record review of the nurses ' note dated 05/02/23 indicated no nurse ' s notes on the next shift addressing the IV after the infusion was completed on 05/02/23. There were no nurses' notes dated 05/03/23 to indicate monitoring for adverse reactions. The nurses note dated 05/04/23 for Resident #1 did not address the IV therapy or the site of the discontinued IV on 05/2/23 and the section for IVs was left blank. Record review of Resident #1 ' s electronic record from 03/1/23 to 06/13/23 did not reveal a consent for the nutrition IV infusion. During an interview on 06/13/23 at 12:09 p.m., Resident #1 said there was no education provided about the nutrition IV infusion. She denied being told about side effects and did not remember signing a consent for the IV infusion. 2. Record review of a face sheet dated 06/13/23 indicated Resident #7 was a [AGE] year-old-female admitted [DATE] with diagnoses including COPD (a disease that cause airflow blockage and breathing-related problems), dementia (a group of thinking and social symptoms that interfere with daily functioning), high blood pressure, protein-calorie malnutrition (the state of inadequate intake of food and nutrients) and vitamin D deficiency (not having enough vitamin D in your body). Record review of a quarterly MDS dated [DATE] indicated Resident #7 had a BIMS score of 15 indicating she was cognitively intact, she needed supervision for bed mobility, transfers, toileting, dressing and hygiene. This quarterly MDS indicated she received IV therapy while a resident in the facility during the past 14 days. Record review of Resident #7 ' s care plans updated 03/23/23 did not address IV therapy to include what adverse reactions were to be monitored, and there was no documentation regarding who would monitor the resident for adverse reactions from the cognitive infusion therapy or for how often. Record review of physician orders dated April 2023 indicated Resident #7 was prescribed a cognitive infusion IV one time dose 250 ml normal saline 0.9% at 250 ml/hr Vitamin C (water soluble vitamin) 5 gm, B Complex-(water soluble vitamins) B1- 200 mg, B2 4 mg, B3 200 mg, B5 4 mg, B6 4 mg,B5 250 mg, B7 Biotin 20 mg, B12 Methyl cobalamin 2000 mcg, Magnesium Chloride 1000 mg, Calcium Gluconate 200 mg, Zinc 10 mg, Amino Blend, Calcium Gluconate 200 mg, Arginine 500 mg, Ornithine 150 mg, Lysine 250 mg, Citrulline 250 mg, Taurine 100 mg, Glycine 100 mg. Record review of a MAR dated April 2023 indicated Resident #7 received the cognitive IV infusion on 04/05/23 at 12:25 p.m. by Contract IV RN. Record review of a Nurses ' Note dated 04/05/23 at 12:30 a.m., for Resident #7 indicated the following . VS 123/84 97.4 82 17 {redacted} INFUSION NOTE: Resident has been cleared for IV nutrient therapy by the Facility's Physician. Current meds were reviewed, if any, and all contraindications have been found. Reviewed resident allergies. Order verified. Assessment completed. Resident prepared for IV vitamin infusion. Site prepared per protocol 22g LAC x 1 attempts. IV site secured per protocol no redness or signs of infiltration. Infusion for wellness r/multiple comorbidities and promote the immune system r/t infectious process. Order: 0.9% Normal Saline 250ML, {redacted} INFECTION PROTOCOL (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455594 If continuation sheet Page 3 of 13 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 06/14/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Infusion started @ 250ML/hr on dial a flow. Patient in no distress, IV site without redness, edema, signs of infiltration. Patient comfortable and denies needs. 1330 Infusion complete. Resident tolerated infusion without difficulty or complication. IV dc'd gauze and Coban to site. Report of infusion completion, indicated as entered by Contract IV RN. Record review of a Post IV Infusion Evaluation dated 04/05/23 for Resident #7 indicated he received an IV for hydration/ wellness over 60 minutes with no adverse reaction noted post infusion. Record review of Resident #7 ' s electronic record from 04/01/23 though 06/13/23 did not reveal a consent for the cognitive IV infusion. During an observation and interview on 06/14/23 at 10:00 a.m., Resident #7 was alert and oriented sitting on her bed. Resident #7 said one of the facility nurses, (unsure who) told her about the IV for vitamins and hydration but did not mention the side effects, or cost. Resident #7 said she did not remember signing a consent, but she gave them permission and agreed to do it. 3. Record review of face sheet dated 06/13/23 indicated Resident #10 was an [AGE] year-old female admitted [DATE] with diagnoses including diabetes and gout (a form of arthritis characterized by severe pain, redness, and tenderness in joints). Record review of a quarterly MDS dated [DATE] indicated Resident #10 had a BIMS score of 15 indicating she was cognitive intact, she needed supervision for transfers, toileting, and hygiene. This quarterly MDS for Resident #10 indicated she had received an IV infusion. Record review of Resident #10 ' s most recent care plan dated 03/23/23, with planned revision date of 06/21/23, gave no indication for the IV therapy to include what adverse reactions were to be monitored, how often the resident should be monitored, or who would monitor the resident for adverse reactions. Record review of physician orders dated April 2023 for Resident #10 included Derma Infusion IV (250ml). Ingredients included Vitamin C (5000 mg). B-Complex which consisted of B1 (200 mg), B4 (4 mg), B3 (200 mg), B5 (4 mg), B6 (4mg), and B7-Biotin (20mg). Also, Zinc (10 mg), Amino blend, Glutamine 150 mg, Arginine 500 mg, Ornithine 150 mg, Kysine 250 mg, and Citruline 250 mg. Record review of Nursing Note dated 04/05/23 at 12:00 p.m. for Resident #10 indicated the following: .VS 133/79 97.3 80 17 [redacted] INFUSION NOTE: Resident has been cleared for IV nutrient therapy by the Facility Physician. Current meds were reviewed, if any, and all contraindications have been found. Reviewed resident allergies. Order verified. Assessment completed. Resident prepared for IV vitamin infusion. Site prepared per protocol 22 g LH x2 attempts. IV site secured per protocol no redness or signs of infiltration. Infusion for wellness r/t multiple comorbidities, promote skin/tissue health, and promote the immune system. Order: 0.9% Normal Saline 250 ml, [redacted] Derma Protocol Infusion started at 250 ml/hr on dial a flow. Patient in no distress, IV site without redness, edema, signs of infiltration. Patient comfortable and denies needs. 1300 Infusion complete. Resident tolerated infusion without difficulty or complication. IV dc ' d gauze and Coban to site. Report of infusion complete. Indicated as entered by Contract IV RN. Record review of Post IV Infusion Evaluation dated 04/05/23 indicated Resident #10 had no adverse reactions noted during the derma infusion. There were no other post evaluations documented by facility staff after the dates of the infusions for Resident #10. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455594 If continuation sheet Page 4 of 13 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 06/14/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of a quarterly MDS dated [DATE] indicated Resident #10 had a BIMS score of 14 indicating she was cognitively intact, she needed supervision for transfers, toileting, and hygiene, and she received IV therapy. Record review of physician orders dated May 2023 for Resident #10 included Derma Infusion IV (250ml). Ingredients included Vitamin C (5000 mg). B-Complex which consisted of B1 (200 mg), B4 (4 mg), B3 (200 mg), B5 (4 mg), B6 (4mg), and B7-Biotin (20mg). Also, Zinc (10 mg), Amino blend, Glutamine 150 mg, Arginine 500 mg, Ornithine 150 mg, Kysine 250 mg, and Citruline 250 mg. Record review of Nursing Note dated 05/02/23 at 11:00 a.m. for Resident #10 indicated the following: .VS 110/66 97.0 71 17 [redacted] INFUSION NOTE: Resident has been cleared for IV nutrient therapy by the Facility Physician. Current meds were reviewed, if any, and all contraindications have been found. Reviewed resident allergies. Order verified. Assessment completed. Resident prepared for IV vitamin infusion. Site prepared per protocol 22 g LAC x1 attempt. IV site secured per protocol no redness or signs of infiltration. Infusion for wellness r/t multiple comorbidities, promote skin/tissue health, and promote the immune system. Order: 0.9% Normal Saline 250 ml, [redacted] Derma Protocol Infusion started at 250 ml/hr on dial a flow. Patient in no distress, IV site without redness, edema, signs of infiltration. Patient comfortable and denies needs. 1200 Infusion complete. Resident tolerated infusion without difficulty or complication. IV dc ' d gauze and Coban to site. Report of infusion complete. Indicated as entered by Contract IV RN. Record review of Post IV Infusion Evaluation dated 05/02/23 indicated Resident #10 had no adverse reactions noted during the derma IV infusion. There were no other post evaluations documented by facility staff after the dates of the infusions for Resident #10. Record review of Resident #10 ' s electronic record for 04/01/23 through 05/30/23, did not reveal a consent for the derma IV infusion. During an interview on 06/13/23 at 11:00 a.m., Resident #10 said a female, who did not work at the facility, came into her room and told her she was to receive a vitamin infusion. She said she did not know who this nurse was, and she had not seen her in the facility except for during infusions. She said she was not told why she was receiving or any possible adverse reactions. She was not offered a consent to sign, and she did not sign one for either infusion. She said the infusion took about 20-25 minutes and all the residents who received the vitamin infusions were gathered in the sitting area behind the therapy gym so the nurse could watch all at one time. 4. Record review of a face sheet dated 06/13/23 indicated Resident #13 was a [AGE] year-old-male admitted [DATE] with diagnoses including stroke and malnutrition. Record review of a quarterly MDS dated [DATE] indicated Resident #13 had a BIMS score of 14 indicating he was cognitive intact, needed supervision for transfers, toileting, and hygiene, and received IV therapy during last 14 days while being a resident. Record review of Resident #13 ' s most recent care plan dated 03/23/23 did not address the IV therapy to include what adverse reactions were to be monitored nor was there documentation regarding who would monitor the resident for adverse reactions from the cognitive infusion therapy or for how often. Record review of physician orders dated April 2023 indicated Resident #13 had orders and included (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455594 If continuation sheet Page 5 of 13 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 06/14/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Cognition Infusion IV (250ml) one time dose 250 ml normal saline 0.9% at 250 ml/hr Vitamin C (water soluble vitamin) 5 gm, B Complex-(water soluble vitamins) B1- 200 mg, B2 4 mg, B3 200 mg, B5 4 mg, B6 4 mg,B5 250 mg, B7 Biotin 20 mg, B12 Methyl cobalamin 2000 mcg, Magnesium Chloride 1000 mg, Calcium Gluconate 200 mg, Zinc 10 mg, Amino Blend, Calcium Gluconate 200 mg, Arginine 500 mg, Ornithine 150 mg, Lysine 250 mg, Citrulline 250 mg, Taurine 100 mg, Glycine 100 mg. Record review of MAR dated April 2023 indicated Resident #13 received the cognitive IV infusion on 04/05/23 at 9:09 a.m. by Contract IV RN. Record review of the nurse ' s notes for Resident #13 indicated he received the cognitive IV infusion on 04/05/23 with no follow up noted after the infusion dates. Record review of Post IV Infusion Evaluation dated 04/05/23 indicated Resident #13 had no adverse reactions were noted during the nutrition infusion or 4 hours later. There were no other post evaluations made after the dates of the infusions for Resident #13 until May 2023 when he received the infusion again. Record review of a quarterly MDS dated [DATE] indicated Resident #13 had a BIMS score of 15 indicating he was cognitive intact, needed supervision for transfer, toileting, and hygiene, and he received IV therapy during last 14 days while being a resident. Record review of physician orders dated May 2023 indicated Resident #13 had orders and included Cognition Infusion IV (250ml) one time dose 250 ml normal saline 0.9% at 250 ml/hr Vitamin C (water soluble vitamin) 5 gm, B Complex-(water soluble vitamins) B1- 200 mg, B2 4 mg, B3 200 mg, B5 4 mg, B6 4 mg,B5 250 mg, B7 Biotin 20 mg, B12 Methyl cobalamin 2000 mcg, Magnesium Chloride 1000 mg, Calcium Gluconate 200 mg, Zinc 10 mg, Amino Blend, Calcium Gluconate 200 mg, Arginine 500 mg, Ornithine 150 mg, Lysine 250 mg, Citrulline 250 mg, Taurine 100 mg, Glycine 100 mg. Record review of MAR dated May 2023 indicated Resident #13 received the cognitive IV infusion on 05/02/23 at 9:09 a.m. by Contract IV RN. Record review of the nurse ' s notes for Resident #13 indicated he received the cognitive infusion on 05/02/23 at 10:11 a.m., for Resident #13 indicated the following . VS . INFUSION NOTE: Resident has been cleared for IV nutrient therapy by the Facility's Physician. Current meds were reviewed, if any, and all contraindications have been found. Reviewed resident allergies. Order verified. Assessment completed. Resident prepared for IV vitamin infusion. Site prepared per protocol 22g LH x 1 attempts. IV site secured per protocol no redness or signs of infiltration. Infusion for wellness r/multiple comorbidities and promote the immune system r/t infectious process. Order: 0.9% Normal Saline 250ML, {redacted} Cognitive PROTOCOL Infusion started @ 250ML/hr on dial a flow. Patient in no distress, IV site without redness, edema, signs of infiltration. Patient comfortable and denies needs. 1111 Infusion complete. Resident tolerated infusion without difficulty or complication. IV dc'd gauze and Coban to site. Report of infusion completion, indicated as entered by Contract IV RN and with no follow up noted after the infusion date. Record review of Post IV Infusion Evaluation dated 05/02/23 indicated Resident #13 had no adverse reactions noted during the nutrition infusion or 4 hours later. There were no other post evaluations made by facility staff after the dates of the infusions for Resident #13. Record review of Resident #13 ' s electronic record did not reveal a consent for the cognitive IV (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455594 If continuation sheet Page 6 of 13 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 06/14/2023 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 0684 infusion from 03/1/23 to 06/13/23. Level of Harm - Immediate jeopardy to resident health or safety During an interview on 06/13/23 at 11:35 a.m., Resident #13 said, They said I was on a list to get IV vitamins; that ' s all that was told so I took the IV vitamins. He said the lady was the one who started the IV and administered the vitamins and he had never seen her in the facility before. Resident #13 said the IV fluids went in within 20 minutes. Resident #13 said there were several residents in the back area with IVs running. He said the nurses just said it was vitamins and did not explain the side effects. Resident #13 said he could not name the nurses or the lady who did the IV. Residents Affected - Some 5. Record review of a face sheet dated 06/13/23 indicated Resident #15 was a [AGE] year-old-female admitted [DATE] with diagnoses including Alzheimer's ' disease (brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest task) chronic kidney disease (your kidneys are damaged and can't filter blood the way they should) and hypertensive chronic kidney disease (high blood pressure caused by damage to the kidneys that can occur in people with chronic kidney disease when the arteries servicing the kidneys become narrow and hardened). Record review of physician orders dated January 2023 indicated Resident #15 was prescribed a cognitive infusion IV one time dose of 250 ml normal saline 0.9% at 250 ml/hr Vitamin C (water soluble vitamin) 5 gm, B Complex-(water soluble vitamins) B1- 200 mg, B2 4 mg, B3 200 mg, B5 4 mg, B6 4 mg,B5 250 mg, B7 Biotin 20 mg, B12 Methyl cobalamin 2000 mcg, Magnesium Chloride 1000 mg, Calcium Gluconate 200 mg, Zinc 10 mg, Amino Blend, Calcium Gluconate 200 mg, Arginine 500 mg, Ornithine 150 mg, Lysine 250 mg, Citrulline 250 mg, Taurine 100 mg and Glycine 100 mg. Record review of a MAR dated January 2023 indicated Resident #15 received the cognitive IV infusion on 01/03/23 at 3:43 p.m. by Contract IV RN. Record review of a Nurses ' Note dated 01/03/23 at 10:11 a.m., for Resident #15 indicated the following . VS 119/67 73 97.2 18 {redacted} INFUSION NOTE: Resident has been cleared for IV nutrient therapy by the Facility's Physician. Current meds were reviewed, if any, and all contraindications have been found. Reviewed resident allergies. Order verified. Assessment completed. Resident prepared for IV vitamin infusion. Site prepared per protocol 22g LH x 2 attempts. IV site secured per protocol no redness or signs of infiltration. Infusion for wellness r/multiple comorbidities and promote the immune system r/t infectious process. Order: 0.9% Normal Saline 250ML, {redacted} INFECTION PROTOCOL Infusion started @ 250ML/hr on dial a flow. Patient in no distress, IV site without redness, edema, signs of infiltration. Patient comfortable and denies needs. 1351 Infusion complete. Resident tolerated infusion without difficulty or complication. IV dc'd gauze and Coban to site. Report of infusion completion, indicated as entered by Contract IV RN. Record review of a Post IV Infusion Evaluation dated 01/03/23 for Resident #15 indicated she received an IV for hydration/ wellness over 60 minutes with no adverse reaction noted post infusion by Contract IV RN. Record review of a quarterly MDS dated [DATE] indicated Resident #15 had a BIMS score of 3 indicating she had severely impaired cognition, she needed extensive assistance for bed mobility, transfers, toileting, and hygiene. This quarterly MDS indicated Resident #15 received IV therapy while a resident in the facility during the past 14 days. Record review of Resident #15 ' s care plans updated 05/08/23 did not address the IV therapy to include what adverse reactions were to be monitored nor was there documentation regarding who would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455594 If continuation sheet Page 7 of 13 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 06/14/2023 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 0684 monitor the resident for adverse reactions from the cognitive infusion therapy or for how often. Level of Harm - Immediate jeopardy to resident health or safety Record review of physician orders dated May 2023 indicated Resident #15 was prescribed a cognitive infusion IV one time dose of 250 ml normal saline 0.9% at 250 ml/hr Vitamin C (water soluble vitamin) 5 gm, B Complex-(water soluble vitamins) B1- 200 mg, B2 4 mg, B3 200 mg, B5 4 mg, B6 4 mg,B5 250 mg, B7 Biotin 20 mg, B12 Methyl cobalamin 2000 mcg, Magnesium Chloride 1000 mg, Calcium Gluconate 200 mg, Zinc 10 mg, Amino Blend, Calcium Gluconate 200 mg, Arginine 500 mg, Ornithine 150 mg, Lysine 250 mg, Citrulline 250 mg, Taurine 100 mg and Glycine 100 mg. Residents Affected - Some Record review of a MAR dated May 2023 indicated Resident #15 received the cognitive IV infusion on 05/02/23 at 09:19 a.m. by Contract IV RN. Record review of a Nurses ' Note dated 05/02/23 at 10:11 a.m., for Resident #15 indicated the following . VS 88/55 97.0 85 18 {redacted} INFUSION NOTE: Resident has been cleared for IV nutrient therapy by the Facility's Physician. Current meds were reviewed, if any, and all contraindications have been found. Reviewed resident allergies. Order verified. Assessment completed. Resident prepared for IV vitamin infusion. Site prepared per protocol 22g LH x 1 attempts. IV site secured per protocol no redness or signs of infiltration. Infusion for wellness r/multiple comorbidities and promote the immune system r/t infectious process. Order: 0.9% Normal Saline 250ML, {redacted} INFECTION PROTOCOL Infusion started @ 250ML/hr on dial a flow. Patient in no distress, IV site without redness, edema, signs of infiltration. Patient comfortable and denies needs. 1111 Infusion complete. Resident tolerated infusion without difficulty or complication. IV dc'd gauze and Coban to site. Report of infusion completion, indicated as entered by Contract IV RN. Record review of Resident #15 nurse's note dated 05/02/23 indicated Resident #15 received the cognitive infusion, had no complications or redness at injection site and no adverse reaction by LVN D (facility staff). There was no follow up noted after the infusion date. Record review of a Post IV Infusion Evaluation dated 05/02/23 for Resident #15 indicated she received an IV for hydration/ wellness over 60 minutes with no adverse reaction noted post infusion by Contract IV RN. Record review of Resident #15 ' s electronic record from 04/01/23 though 06/13/23 did not reveal a consent for the cognitive IV infusion. During an observation and interview on 06/13/23 at 11:28 a.m., Resident #15 was alert and sitting in her wheelchair. Resident #15 said she remembered getting an IV last month, but she did not remember anything about it or anyone telling her anything about it. During a family interview on 06/13/23 at 12:00 p.m., Resident #15 ' s daughter said the facility did not call her and ask her about the IV nutrients. She said she was not aware her mother received IV nutrients. She said she did not sign a consent for the IV. 6. Record review of a face sheet dated 06/13/23 indicated Resident #19 was a [AGE] year-old-female admitted [DATE] and readmitted [DATE] with diagnoses including hemiplegia of the left side (paralysis of one side of the body), stroke, diabetes mellitus (disease of inadequate control of blood levels of glucose) and morbid obesity. Record review of a quarterly MDS dated [DATE] indicated Resident #19 had a BIMS score of 15 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455594 If continuation sheet Page 8 of 13 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 06/14/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some indicating she was cognitively intact, and she needed extensive assistance for bed mobility, transfers, toileting, dressing, and hygiene. This quarterly MDS indicated Resident #19 received IV therapy while a resident in the facility during the past 14 days. Record review of Resident #19 ' s care plans updated 03/28/23 did not address the IV infusion therapy to include what adverse reactions were to be monitored nor was there documentation regarding who would monitor the resident for adverse reactions from the cognitive infusion therapy or for how often. Record review of physician orders dated April 2023 indicated Resident #19 was prescribed an infection infusion IV one time dose of 250 ml normal saline 0.9% at 250 ml/hr Vitamin C (water soluble vitamin) 5 gm, B Complex-(water soluble vitamins) B1- 200 mg, B2 4 mg, B3 200 mg, B5 4 mg, B6 4 mg,B5 250 mg, Zinc 10 mg, Amino Blend, Glutamine 150 mg, Arginine 500 mg, Ornithine 150 mg, Lysine 250 mg, Citrulline 250 mg and Glutathione 600 mg. Record review of a MAR dated April 2023 indicated Resident #19 received the infection infusion on 04/05/23 at 12:47 p.m. by Contract IV RN. Record review of a Nurses ' Note dated 04/05/23 at 12:43 p.m., for Resident #19 indicated the following . VS 88/55 97.0 85 18 {redacted} INFUSION NOTE: Resident has been cleared for IV nutrient therapy by the Facility's Physician. Current meds were reviewed, if any, and all contraindications have been found. Reviewed resident allergies. Order verified. Assessment completed. Resident prepared for IV vitamin infusion. Site prepared per protocol 22gRAC x 1 attempts. IV site secured per protocol no redness or signs of infiltration. Infusion for wellness r/multiple comorbidities and promote the immune system r/t infectious process. Order: 0.9% Normal Saline 250ML, {redacted} INFECTION PROTOCOL Infusion started @ 250ML/hr on dial a flow. Patient in no distress, IV site without redness, edema, signs of infiltration. Patient comfortable and denies needs. 1120 Infusion complete. Resident tolerated infusion without difficulty or complication. IV dc'd gauze and Coban to site. Report of infusion completion, indicated as entered by Contract IV RN. There was no follow up noted after the infusion date. Record review of a Post IV Infusion Evaluation dated 04/05/23 for Resident #19 indicated she received an IV for infection/viral and hydration over 60 minutes with no adverse reaction noted post infusion by Contract IV RN. Record review of physician orders dated May 2023 indicated Resident #19 was prescribed an infection infusion IV one time dose of 250 ml normal saline 0.9% at 250 ml/hr Vitamin C (water soluble vitamin) 5 gm, B Complex-(water soluble vitamins) B1- 200 mg, B2 4 mg, B3 200 mg, B5 4 mg, B6 4 mg,B5 250 mg, Zinc 10 mg, Amino Blend, Glutamine 150 mg, Arginine 500 mg, Ornithine 150 mg, Lysine 250 mg, Citrulline 250 mg and Glutathione 600 mg. Record review of a MAR dated May 2023 indicated Resident #19 received the infection IV infusion on 05/02/23 at 9:19 a.m. by Contract IV RN. Record review of Resident #19 ' s nurse's note dated 05/02/23 indicated Resident #19 received the infection/viral and hydration IV infusion and she tolerated it without difficulty or complications by Contract IV RN. Record review of a Nurses ' Note dated 05/02/23 at 10:20 a.m., for Resident #19 indicated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455594 If continuation sheet Page 9 of 13 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 06/14/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety following . VS 88/55 97.0 85 18 {redacted} INFUSION NOTE: Resident has been cleared for IV nutrient therapy by the Facility's Physician. Current meds were reviewed, if any, and all contraindications have been found. Reviewed resident allergies. Order verified. Assessment completed. Resident prepared for IV vitamin infusion. Site prepared per protocol 22gRAC x 1 attempts. IV site secured per protocol no redness or signs of infiltration. Infusion for wellness r/multiple comorbi[TRUNCATED] Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455594 If continuation sheet Page 10 of 13 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 06/14/2023 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 ensure residents who require dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 15 residents (Resident # 3) reviewed for dialysis. Residents Affected - Few The facility failed to have a physician's order for dialysis for Resident #39. This failure could place the residents at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Record review of physician orders dated 6/13/23 indicated Resident #39, re-admitted [DATE], was [AGE] years old with, end stage renal disease (condition in which a person's kidneys cease to function on a permanent basis leading to the need for dialysis) and diabetes. The orders indicated the resident received a renal diet. There was not an order for dialysis (a process used to remove excess water, solutes and toxins in the blood in people whose kidneys no longer function properly). Record review of the most recent completed admission MDS assessment dated [DATE] indicated Resident #39 received dialysis services. Record review of a care plan dated 06/06/23 indicated Resident #39 had end stage renal disease and was dependent on dialysis and had a right subclavian (the artery just below the clavicle bone) dialysis port. The dialysis center was to change the dressing to the port. During observation and interview on 06/14/23 at 8:40 a.m., Resident #39 had a dressing to the right subclavian artery. The resident said the dressing covered his dialysis port and the dialysis center changed the dressing. The resident said he went to dialysis 3 times a week and the facility insured the resident got to and from dialysis. During an interview on 06/14/23 at 8:53 a.m., LVN A said there was not an order for Resident #39's dialysis and there should be. She said the resident was admitted and discharged a few times and had been on dialysis services prior to the most recent admission. She said she was supposed to review the orders to make sure they were correct. She said the DON was responsible for reviewing the orders to make sure they were correct. She said she did not notice the order for dialysis was left off Resident #39's orders . She said the possible negative outcome of not having an order for dialysis would be the resident might not receive the services he needed. During an interview on 06/14/23 at 8:56 a.m., the DON said Resident #39 did not have orders for dialysis but should. She said she and LVN B were responsible to ensure the orders were correct. She said they reviewed all resident orders for accuracy upon admission and re-admission. She said the resident had been in and out of the hospital and the dialysis orders must have been overlooked when the resident was readmitted on [DATE]. She said her expectations were for the resident's orders to be correct. She said the possible negative outcome of not having orders for dialysis would be the resident could possibly not receive the services they needed and in turn it could cause a decline in the resident's well-being. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455594 If continuation sheet Page 11 of 13 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 06/14/2023 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 06/14/23 at 9:14 a.m., LVN B said she was responsible for ensuring all new admission orders were correct. She said Resident #39 did not have orders for dialysis but should. She said the possible negative outcome of not having an order in place would be the resident may not receive the needed services to prevent decline, weight changes and/or fluid overload. A Dialysis Services policy dated 6/2019 indicated: . The hemodialysis procedure will be under the direct responsibility and supervision of an offsite contracted dialysis agency through an order by the attending physician. A Physician Order policy dated 6/2019 indicated: It is the policy of this facility that qualified licensed nurses will obtain and transcribe orders according to Facility Practice Guidelines. admission: 1) The qualified licensed nurse reviews orders from the transfer record from an acute care hospital or other entity. 2) A call is placed to the physician to confirm the orders and request any additional orders as needed. In the event the physician writing the transfer orders is not credentialed by the facility, the designated attending physician is contacted to confirm the transfer orders and request any additional orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455594 If continuation sheet Page 12 of 13 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 06/14/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, record review the facility failed to ensure drugs and biologicals were stored in locked compartments in accordance with state and federal laws for 1 of 4 medication carts reviewed for drug storage. (Hall 100 medication aide cart) The facility failed to secure the medication aide cart for Hall 100. This failure could place residents at risk for an adverse drug event and drug diversion. Findings included: During an observation on 06/11/23 at 8:20 a.m. to 8:25 a.m., the Hall 100 medication cart was left unlocked in the dining room where 12 residents were sitting with no staff in sight. The cart contained oral prescription medications and eye drops for Hall 100 residents such as blood pressure medication, fluid medications, antiseizure medications, heart medications, eye drops and stock meds (vitamins, Tylenol and laxatives). During the observation on 06/11/23 at 8:26 a.m., LVN E walked up towards the medication cart from Hall 200 which was around the corner of the medication cart. She looked at the medication cart and she went to the medication cart and locked it. During an interview on 06/11/23 at 8:40 a.m., LVN E said she left the cart unlocked. She said she was trained not to leave the cart unlocked and unattended because residents could get into the cart and take medications not prescribed. During an interview on 06/11/23 at 1:00 p.m., the Administrator said the medications carts should be kept locked when not in use. During an interview on 06/12/23 at 9:45 a.m. the DON said the nurses were trained to lock the medication carts when not in use to prevent the residents from being able to get medications. The DON said she was retraining all the nurses on keeping the medication carts locked since that happened. Record review of the facility's Storage of Medications policy revised August 2020 indicated the following .Medications and biologicals are stored safely, securely, and properly . The medication supple is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Record review of the facility ' s Medication Administration and Management dated June 2019 indicated . Security and Safety Guidelines It is the policy of this that the facility will implement a Medication Management Program that incorporates systems with established goals to meet each residents needs as well as regulatory requirement. 3. Medication cart is kept in sight or locked at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455594 If continuation sheet Page 13 of 13