Inspection·August 21, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 5 residents (Resident#1) reviewed for accuracy of medical records in that: The facility failed to ensure that Resident #1's pain level was documented in the resident's clinical record. This deficient practice could affect residents whose records were maintained by the facility and could place the residents at risk for errors in their care and treatment. Findings included: Record review of Resident #1's face sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included atherosclerotic heart disease of disease of native coronary artery without angina pectoris (a buildup of fat, cholesterol, and other substances in and on the artery walls), type 2 diabetes (high blood sugar), hyperlipidemia (high levels of fat in the blood), essential hypertension (high blood pressure), peripheral vascular disease (circulatory condition in which narrow blood vessels reduce blood flow to the limbs) and lower extremity amputation (loss or removal of body parts) Record review of Resident #1's baseline care plan dated 8/19/24 revealed the resident was alert, had no memory issues and was incontinent of bowel and bladder. Record review of Resident#1's care plan dated 8/20/2024 revealed the following: SKIN CONDITION: (Resident's Name) has non pressure/surgical skin conditions: o (resident name)'s skin condition will be free from signs and symptoms of infection through the review date. o (Resident's Name)'s pain related to the skin condition will be managed through the review date. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 455812 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 455812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at First Colony 4710 Lexington Blvd Missouri City, TX 77459 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)