Health inspection·August 13, 2025

F 0641 today and he smoked cigarettes daily. She said the MDS Nurse was responsible for all MDSs in the facility. Level of Harm - Minimal harm or potential for actual harm 2. Record review of Resident #25's face sheet, dated 08/12/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #25 had diagnoses of high blood pressure, kidney disease and infection of surgery site (abdomen). Residents Affected - Some Record review of Resident #25's physician orders, dated 07/28/25, indicated orders for regular diet mechanical soft texture and contained no orders for feeding tube. Record review of an admission assessment, dated 07/28/25, indicated no gastric tube feeding (surgically placed tube for feeding). Record review of Resident #25's care plan, initiated 07/02/25, indicated Resident #25 was at risk of unplanned weight loss and interventions included assist her with eating as needed. The care plan did not document gastric tube feeding. Record review of Resident #25 annual MDS assessment, dated 07/15/25, indicated Resident #25 was marked for nutritional approach of feeding tube during the last seven days of the assessment period. The assessment indicated Resident #25 received > 51 % of calorie intake while she was a resident. The BIMS score of 12 of 15, which indicated moderate impaired cognition. During an observation and interview on 8/12/25 at 12:15 p.m., indicated Resident #25 was eating her lunch, a mechanical soft diet. She said she ate soft foods and said she never had a feeding tube. During an interview on 08/13/25 at 9:00 a.m., the DON said the MDS nurse coded the nutritional approach in error. There were 2 admits that day and she coded Resident #25 wrong. She said the error could cause the resident to not get the services she required. During an interview on 08/13/25 at 9:30 a.m., the MDS nurse said she coded Resident #25 wrong, she said she was responsible and used the RAI manual for policy and instructions. 3. Record review of Resident #39’s face sheet, dated 08/11/25, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #39 had diagnoses which included dementia (a progressive decline in cognitive functions memory, thinking, language, judgement and behavior) and nicotine dependence (nicotine addiction) as of 08/16/23. Record review of a Smoking safety screen, dated 05/13/25, indicated Resident #39 was safe to smoke with supervision, resident used Skoal dip and did not smoke at this time. Record review of Resident #39’s care plan, initiated 05/30/25, indicated Resident #39 used tobacco with interventions that included adequate supervision and staff would store and distribute the resident’s tobacco materials. Record review of Resident #39’s annual MDS assessment, dated 10/26/24, indicated Resident #39 was not marked for current tobacco use during the assessment period. The assessment indicated Resident #4 had a BIMS score of 3 of 15, which indicated severely impaired cognition with diagnoses of dementia and nicotine dependence. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455594 If continuation sheet Page 2 of 9 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 08/13/2025 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #39’s quarterly MDS assessment, dated 07/29/25, indicated Resident #39 had a BIMS score of 9 of 15, which indicated moderately impaired cognition with diagnoses of dementia and nicotine dependence. 4. Record review of Resident #40’s face sheet, dated 08/13/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #40 had a diagnosis which included cerebral palsy (congenital disorder with abnormal brain development). Record review of Resident #40’s physician orders, dated 08/01/25, indicated orders for regular diet mechanical soft texture and contained no orders for feeding tube. Record review of Resident #40’s care plan, initiated on 08/03/17 and revised 08/22/24, indicated Resident #40 was positive for PASRR with ID and IDD and received special services. Record review of Resident #40’s annual MDS assessment, dated 01/23/25, indicated Resident #40 was coded no for having ID or DD. Resident #40 had a BIMS score of 13 of 15, which indicated the resident was cognitively intact. During an interview on 08/13/25 at 9:00 a.m., the DON said the MDS for Resident #40 should had been coded yes for ID or DD and was not correct. She said her expectation was for the MDS to be correct and accurately. During an interview on 08/13/25 at 9:30 a.m., the MDS nurse said she was responsible, and she coded Resident #40’s PASRR wrong and she would correct it. During an observation and interview on 08/11/25 at 11:30 a.m., Resident #39 was up in his wheelchair, he said he dipped tobacco during the smoke time, the staff kept his tobacco supplies and monitored him during smoking time. He said he was aware of when the smoking times were. During an observation on 08/11/2025 at 2:30 p.m., Resident #39 was observed dipping during the smoke time, staff were observed providing his dipping supplies and monitored him during smoking time and provided a spit cup. During an interview on 08/12/25 at 1:45 p.m., RN A said she provided care for Resident #39 today and he dipped Skoal daily. She said the MDS Nurse was responsible for all MDSs in the facility. 5. Record review of Resident #41’s face sheet, dated 08/13/25, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #41 had diagnoses which included stroke (damage to the brain from interruption of its blood supply) and tobacco use. Record review of a Smoking safety screen, dated 05/13/25, indicated Resident #41 was safe to smoke with supervision. Record review of Resident #41’s care plan, initiated 07/16/24, indicated Resident #41 was a smoker of cigarettes with interventions that included adequate supervision and staff would store and distribute the resident’s smoking materials. Record review of Resident #41’s annual MDS assessment, dated 07/23/25, indicated Resident #41 was not marked for current tobacco use during the assessment period. The assessment indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455594 If continuation sheet Page 3 of 9 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 08/13/2025 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #41 had a BIMS score of 13 of 15, which indicated intact cognition. Resident #41 had a diagnosis of stroke. During an observation and interview on 08/11/25 at 9:00 a.m., Resident #41 was sitting on his bed and said he was treated well, he said he smoked daily, staff kept smoking supplies and monitored him during smoking times. He said he was aware of the smoking times. During an observation on 08/11/2025 at 2:30 p.m., Resident #41 was observed smoking, staff were observed lighting the cigarette and provided smoking supplies and monitored the resident during smoking episode. During an interview on 08/12/25 at 1:45 p.m., RN A said she provided care for Resident #41 today (08/12/25) and he smoked cigarettes daily. She said the MDS Nurse was responsible for all MDSs in the facility. During an interview on 08/12/2025 at 1:45 p.m., the MDS Nurse said she was responsible for all MDSs in the facility, and she coded tobacco use on the MDSs for all smokers and tobacco chewer/ dippers. She said the Regional MDS Nurse double checked random MDSs for accuracy. She said she was educated on completion of MDSs with 07/15/25 the most recent training. The MDS nurse said Resident #39 dipped tobacco daily and Resident #4 and Resident #41 smoked daily. She said there MDSs were not coded for tobacco use on the Annual MDS. She said she thought she marked the MDS for tobacco use but may have double clicked it. She said there was no resident risk of tobacco use not marked on the MDS. She said the MDS assessment just did not accurately describe the resident. During an interview on 08/12/2025 at 2:00 p.m., the DON said the MDS Nurse was responsible for all MDSs in the facility and was educated on completion of the MDSs. She said the Regional MDS Nurse was her backup who randomly checked the MDSs. The DON said she thought the MDS Nurse marked the MDS for tobacco use but it unclicked when the MDS was completed. She said there was no resident risk from an MDS not marked for tobacco use and the resident used tobacco. She said the MDS did not accurately describe the resident. The DON said her expectation was all MDSs completed accurately and timely. During an interview on 08/12/2025 at 2:14 p.m., the Administrator said the MDS Nurse was responsible for all MDSs in the facility and was educated on completion of MDSs. She said the Regional MDS Nurse was the MDS Nurse’s backup who randomly checked MDSs. The Administrator said she thought the MDS Nurse marked the MDS for tobacco use but it unclicked when the MDS was completed. She said there was no resident risk of an MDS not marked for tobacco use when the resident used tobacco. She said the MDS just did not accurately describe the resident. The Administrator said her expectation was all MDSs were completed accurately and timely. During an interview on 08/12/2025 at 4:20 p.m., the Regional MDS Nurse said the MDS Nurse was responsible for all MDSs in the facility. She said the facility did not have a back up to double check MDSs. She said she did random audits of random MDSs for completion. The Regional MDS Nurse said the MDS Nurse was educated with July the most recent education. She said tobacco use was overlooked on the MDSs. The Regional MDS Nurse said there was no resident risk of tobacco use marked incorrectly on the MDS, just incorrect coding. Record review of the facility’s policy titled, “Minimum Data Set (MDS)” revised 06/2019, indicated . The interdisciplinary team will complete the MDS for each patient/resident as part of the RAI process to assure data accuracy of its state-specific version of such within the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455594 If continuation sheet Page 4 of 9 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 08/13/2025 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some required timeframes according to applicable law and regulations. … Data entered on the MDS is based on information about the patient/ resident during the common observation period. The assessment date on the MDS designates the endpoint of the common observation period and all MDS items refer back in time from this point. …2. Interview and observe the patient/ resident to obtain validation of items identified on the medical record and to collect information for items where no documentation exits. …” Record review of the “Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, indicated . J1300: Current Tobacco Use coding … Steps for Assessment 1. Ask the resident if they used tobacco in any form during the 7-day look-back period. 2. If the resident states that they used tobacco in some form during the 7-day look-back period, code 1. Yes. … Coding Instructions, Code, no: if there are no indications that the resident used any form of tobacco. Code 1, yes: if the resident or any other source indicates that the resident used tobacco in some form during the look-back period.… FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455594 If continuation sheet Page 5 of 9 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 08/13/2025 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program under Medicaid to the maximum extent practicable to avoid duplicative testing and effort for 1 of 5 residents (Resident #4) reviewed for PASRR. 1. The facility failed to ensure Resident #4's PL1 was updated to reflect the resident's diagnosis of disorganized schizophrenia (a mental illness characterized by disorganized thinking, speech and behavior and unusual reactions to situations). 2. The facility failed to refer Resident #4 for PASRR Level II assessment to the state designated authority. These failures could place residents at risk for not receiving needed assessment, care, and specialized services to meet their needs. Findings include: Record review of Resident #4's face sheet, dated 08/12/25, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #4 had a diagnosis of disorganized schizophrenia as of 02/11/25. Record review of Resident #4's Psychiatric Initial Assessment, dated 02/11/25, indicated Resident #4 had a primary treating diagnoses of disorganized schizophrenia. Record review of Resident #4's care plan, initiated 02/11/25, indicated Resident #4 received psychotropic medication for schizophrenia which included interventions of monitoring for adverse reactions and behaviors. Record review of Resident #4's PL 1, completed by the referring facility on 07/15/24, indicated the resident was negative for dementia, mental illness, developmental disability, and intellectual disability. Record review of Resident #4's annual MDS assessment, dated 07/26/25, indicated Resident #4 was not considered by the state level II PASRR process to have serious mental illness or intellectual disability or a related condition and a negative Level II Preadmission Screening and Resident Review diagnosis. The assessment indicated Resident #4 had a BIMS score of 14 of 15, which indicated intact cognition with a diagnosis of schizophrenia. Record review of physician's orders, dated 08/13/25, indicated Resident #4 was prescribed Abilify (a medication to treat mental health conditions which included schizophrenia) 10 mg one time a day for schizophrenia with a start date of 05/16/25. Record review of Resident #4's MAR, dated 08/01/25 through 08/11/25, indicated Resident #4 received Abilify 10 mg daily for disorganized schizophrenia from 08/01/23 to 08/11/25. During an observation on 08/11/25 at 9:35 a.m., Resident #4 was sitting on his bed and said he was treated well and received needed care but was unsure of his medication or if he wanted to receive PASRR services. During an interview on 08/11/25 at 11:00 a.m., RN A said she provided care for Resident #4 today (08/11/25) and he received Abilify and had a diagnosis of schizophrenia. During an interview on 08/11/25 at 12:00 p.m., the MDS Nurse said the SW was responsible for PASRR forms in the facility and she keyed them into the LTC system. She said Resident #4 received a schizophrenia diagnosis in February 2025 from the psychiatric physician and needed a 1012 form completed at that time. The MDS Nurse said Resident #4's 1012 form (Mental Illness/ Dementia resident Review form to determine whether the individual has a primary diagnosis or if the individual has a mental illness diagnosis to qualify for PASRR services that was previously PASRR negative) was overlooked, and she would do a 1012 form immediately and send to LITTA and to the LTC system. She said she was educated on completion of PASRR forms. The MDS Nurse said the resident risk of a 1012 form not completed after a new PASRR qualifying diagnoses was received by a resident was a resident could miss out on services. During an interview on 08/12/25 at 9:05 a.m., the SW said she was responsible for PASRR forms in the facility as of September 2024. She said the Administrator was the back up. She said she was educated on completion of PASRR forms with the most recent update in June 2025. The SW said Resident #4's 1012 form was overlooked, she said the psychiatric physician at times notified the nurse on duty of new (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455594 If continuation sheet Page 6 of 9 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 08/13/2025 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete diagnoses and not the SW, the MDS Nurse or the Administrator. She said the nurses not always notify them of a diagnosis change. The SW said the resident risk of a 1012 form not completed on a resident who newly acquired a PASRR qualifying diagnoses was the resident could possibly miss out on services. During an interview on 08/12/25 at 2:30 p.m., the Administrator said the SW was responsible for PASRR forms in the facility, the MDS Nurse keyed the forms into the LTC system, and she was the backup and did some PASRR forms. She said she was ultimately responsible. The Administrator said the staff were educated on completion of PASRR forms. She said Resident #4's new diagnosis was overlooked. The Administrator said the resident risk of a new 1012 form not sent into the LTC system when a resident acquired a PASRR qualifying diagnosis was a resident could possibly miss out on services. She said Resident #4 did not miss out on services, he was already receiving psychology services, weekly visits from the psychology physician, weekly visits for group therapy and received OT from 05/16/25 to 06/20/25 and PT therapy from 05/16/25 to 08/05/25. The Administrator said her expectation was all PASRR forms were accurate. Record review of the facility's policy, titled, PASRR, revised 01/2025, indicated .This policy ensures compliance with federal and Texas Health and Human Services Commission (HHSC) regulations regarding the Preadmission Screening and Resident Review (PASRR) process. The goal is to Identify individuals with Mental Illness (MI), Intellectual Disability (ID), or Developmental Disability/ Related Conditions (DD/RC) and ensure appropriate placement and specialized services.The PASRR Level 1 (PL1) Screening Form is designed to identify individuals who are suspected of having mental illness (MI), intellectual disability (ID), or a developmental disability (DD). A developmental disability is also referred to as a related condition (RC). or nursing facility (NF) will screen the individual and fill out all fields of the PL1 Screening Form and enter the PL1 Screening form into the LTC Online Portal. Record review of the facility's October 2023 Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual titled, A1500: Preadmission Screening and Resident Review (PASRR) Item Rationale Health-related Quality of Life indicated . o All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), developmental disability (DD), or related conditions o Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State Event ID: Facility ID: 455594 If continuation sheet Page 7 of 9 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 08/13/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to properly store, prepare, distribute and serve food in accordance with the professional standards for food service safety for 1 of 3 refrigerators (Refrigerator #1) in the kitchen reviewed for food and nutrition services. The facility failed to ensure food items in Refrigerator #1 were labeled, dated, sealed, and not expired. This failure could place residents at risk for health complications, foodborne illnesses, and decreased quality of life.Finding include:During an observation and interview on 08/11/25 at 8:28 a.m. of Refrigerator #1 with Dietary Aide indicated the following: 1- Ziploc gallon bag of lunchmeat slices was undated and unlabeled as to what was in the bag. The Dietary Aide said it was lunch meat for sandwiches but did not know who opened, or when the lunchmeat was last used. 1-large flat Rubbermaid container half-full of a reddish brown formed substance. There was no label identifying what was in the container and had no date as to when it expired or when it was put in the refrigerator. The Dietary Aide said it was chili but did not know who prepared it, or when the chili was last used. 1-large upright Rubbermaid container of 1/2 block, sliced, yellow cheese was undated and unlabeled as to what was in the container. The Dietary Aide said it was American sliced cheese for sandwiches but did not know who opened, or when the cheese was last used. 1-large, opened Ziploc 2-gallon bag with a ripped open from the seam original manufacture labeled 5lb bag of Mozzarella cheese that was undated, and exposed the cheese to the elements. The Dietary Aide said both Ziploc and cheese bag was opened and exposed the cheese to air. The Dietary Aide said not being sealed the food could get stale. The Dietary Aide said she received orientation training on different types of meals to include how to serve plates, menus, reading the meal ticket, hair nets, glove use, hand hygiene, and many other topics. She said without a date, she would not know when it was placed in the refrigerator and would discard the food to ensure it was safe for residents and not make them sick. During an interview on 08/12/25 at 1:30 p.m., the DM said she was responsible for making sure staff in the kitchen followed the facility policy, checking the pantry, refrigerator, and freezer for expired or spoiled foods at the end of each week. The DM said she could not explain why the expired or spoiled foods had not been removed from the refrigerator. She said all kitchen staff completed the required food preparation and food storage trainings. The DM said the potential harm to residents would be food poisoning, other foods leaking on the not sealed foods, sickness, and food could go stale. The DM said the failure occurred due to staff not paying attention. During an interview on 08/12/2025 at 2:45 p.m., the Administrator said her expectation was all products in the kitchen be labeled and dated correctly and according to facility policy. The Administrator said if residents were served out of date food products it could result in cross-contamination, causing them to get sick. The Administrator said it was the responsibility of the DM to ensure all products were labeled correctly. Record review of the facility's policy titled, Nutritious Lifestyles, dated 12/01/11, read: Policy: Food Storage.All food will be stored according to the state and federal food codes. Guidelines.2. Refrigerators. a. All refrigerated foods are stored per state and federal guidelines.e. All refrigerated foods are dated, labeled and tightly sealed, including leftovers, using clean, nonabsorbent, covered containers that are approved for food storage. All leftovers are used within 48 hours. Items that are over 48 hours old are discarded. Record review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455594 If continuation sheet Page 8 of 9 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 08/13/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete potato flakes, salt, spices, and sugar shall be identified with the common name of the food .3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety Event ID: Facility ID: 455594 If continuation sheet Page 9 of 9