Inspection·October 24, 2024

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinators would be responsible for creating the care plans and that they facility had one MDS Coordinator on site and also had a Regional MDS Nurse. During an interview on 10/4/2024 at 1:00 pm MDS Coordinator A said Resident #43 should have had a baseline care plan to address the resident for skin issues and she missed it. She said Resident #43 was in bed quite a bit, he was care planned for using the urinal, but she should have care planned him for skin issues. She said she used the RAI manual for assessments and care plans. She said that a negative outcome for a resident not care planned for skin could be skin irritation, rashes and possible skin break down. She added that there was another staff that also held responsibility for care plans that worked off-site, MDS Coordinator B and she believed that Resident #43 admitted under skilled care so MDS Coordinator B would have completed Resident #43's initial care plan. During a telephone interview on 10/4/2024 at 1:15 pm with MDS Coordinator B, she said that Resident #43 should have had a care plan to address skin issues and the potential negative outcome could be skin breakdown, if not care planned. She confirmed using the RAI Manual for care plans. Record review of the facility policy entitled; Baseline Care Plan dated revised 6/2024 reflected in part .The Facility will implement a Baseline Care Plan to ensure continuity of care and communication, prevent adverse events, and inform the resident and/or responsible party of the initial care and services . Procedure: A Baseline Care Plan will be developed within 48 hours of admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 2 of 32 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 10/24/2024 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment describing services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 3 residents (Residents #88 and #43) reviewed for comprehensive care plans. 1. The facility failed to care plan Resident #88's behavior of removing her oxygen cannula off her face and not properly storing the cannula when not in use. 2. The facility failed to care plan Resident #43 for potential skin issues due to being always incontinent with bladder and frequently incontinent with bowel . This failure could lead to residents not having their individual, medical, functional, and psychosocial needs identified and cause a physical or psychosocial decline in health. Findings included: 1. Record review of Resident #88's face sheet dated 09/30/2024 revealed a [AGE] year-old who was admitted to the facility on [DATE] with medical diagnoses including: chronic obstructive pulmonary disease (lung condition that limits airflow in and out of the lungs due to swelling and irritation), dysphagia (difficulty swallowing), Major Depressive Disorder, Post-Traumatic Stress Disorder, hypothyroidism (underactive thyroid gland), and hypertension (high blood pressure). Record review of Resident #88's Quarterly MDS assessment dated [DATE] revealed she had a BIMS (short assessment of mental status) score of 15, indicating high cognitive intactness. Further review revealed Resident #88 used a wheelchair and that she was fully independent in all self-care activities except for showering or bathing, where she required set-up or clean-up assistance . Resident #88's MDS did not reflect that she was on oxygen therapy. Record review of Resident #88's MAR (medication administration administration) for September 2024 revealed she had physician orders started on 10/16/2023 for oxygen at 2-6 liters to keep o2 sats above 92% as needed. Record review of Resident #88's physician notes dated 07/02/2024, the MD wrote under her COPD diagnosis: patient has a history of significant COPD, currently symptoms/COPD well-controlled, patient is sometimes noncompliant with keeping the oxygen on, patient has been advised to keep the supplemental oxygen on, understands risks. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 3 of 32 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 10/24/2024 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #88's care plan last reviewed 09/10/2024 revealed she had a focus area of shortness of breath and at risk for respiratory distress/failure and increased episodes of SOB (shortness of breath) as evidenced by COPD diagnosis. Resident #88 refused to be sent to the ER for evaluation after complaining of SOB on 04/29/2024. Interventions included: applying O2 per order, check pulse oximetry as ordered, and observe for s/sx of respiratory infection and report any noted to the MD. Resident #88's care plan did not address her behavior of removing oxygen cannula against physician orders. Observation of Resident #88's room on 09/30/2024 at 9:30am, revealed the oxygen cannula was on the bed underneath two sheets and one blanket near the left edge of the bed. Observation and interview with RN G on 09/30/2024 at 9:30am, revealed RN G came into Resident #88's room and took the cannula out and put it in a clean bag. RN G stated a risk of keeping the cannula on the mattress would be it could catch fire and infection control . Interview with Resident #88 on 09/30/2024 at 12:55pm, she stated that her oxygen was working well and she had no issues and that she measured her own oxygen using her personal pulse oximeter because she was a smoker. She had been educated on oxygen use by staff. Interview with the Administrator and RNC on 09/30/024 at 2:16pm, the RNC said Resident #88 tended to lay her cannula on the sheet. The RNC said that the nurses should have cleaned the cannula when Resident #88 laid it on her bed but that it was not an infection control issue because it was unknown if Resident #88 placed the cannula back on for use without it being cleaned first. The RNC said Resident #88 had been at the facility for a few years and was independent and that nurses did not track or monitor the oxygen while she smokes. Interview with the MDS Coordinator A on 10/05/2024 at 1:01pm, she said that Resident #88 has PRN oxygen orders and that there is was documentation Resident #88 was educated on keeping her oxygen equipment clean and taking care of it. MDS Coordinator A said Resident #88 was care-planned for oxygen, but that MDS Coordinator A recently put in the care plan that Resident #88 tended to take off her cannula and leave the room without cleaning it and storing it. MDS Coordinator A said that Resident #88 leaving the cannula out in the open was an infection control risk because it could end up on the floor which is dirty and where people step on it. MDS Coordinator A said that Resident #88 is documented for respiratory issues and that she should know how to turn off her oxygen concentrator, but that staff are responsible for turning it off if they saw her going down the hall away from her room. Another interview with the Administrator on 10/07/2024 at 2:00pm, she said that each patient had individualized care plans which allowed staff to know how to better take care of the patient as an individual. 2. Record review or Resident #43's admission record dated October 3, 2024 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #43's diagnoses included cerebrovascular disease (conditions that affect blood flow to your brain) and hemiplegia and hemiparesis following cerebral infarction (both conditions that can occur after a cerebral infarction, or stroke, and are characterized by weakness or paralysis on one side of the body). Record review of Resident #43's admissions MDS dated [DATE] revealed a Brief Interview of Mental (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 4 of 32 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 10/24/2024 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Status (BIMS) score of 15 out of 15 revealing he was cognitively intact. The MDS assessment revealed that Resident #43 was impaired on one side with upper extremities and limited on both sides with lower extremities with functional range of motions. Resident #43 was coded to be always incontinent of bladder and bladder. Record review of Resident #43's baseline care plan dated of 5/29/2024 revealed that he was always incontinent with bladder and frequently incontinent with bowel. 1. Urinary continence required assistance to total dependence with his ADL's Record review of Resident #43's comprehensive care plan revealed there was no skin/wound care planned though the area was triggered on the admission CAA (Care Area Assessment summary) dated 6/2/2024. During an interview on 10/3/24 at 1:32pm the DON said that Resident #43 should have a comprehensive care plan to address the potential for skin issues, that Resident #43 was incontinent of bladder and also used the urinal. She added that a potential negative outcome of not having a care plan to address skin issues would be a potential unawareness of required care to provide. She said that the MDS Coordinators would be responsible for creating the care plans and that they facility had one MDS Coordinator on site along with a Regional MDS Nurse. During an interview on 10/4/2024 at 1:00 pm MDS Coordinator A said that Resident #43 should have a comprehensive care plans to address the resident for skin issues and she missed it. She said Resident #43 was in bed quite a bit, he was care planned for using the urinal, but she should have care planned him for skin issues. She said she used the RAI manual for assessments and care plans. She said that a negative outcome for a resident not care planned for skin could be skin irritation, rashes and possible skin break down. She added that there was another staff that also held responsibility for care plans that works off-site, MDS Coordinator B and she believed that Resident #43 admitted under skilled care so MDS Coordinator B would have completed Resident #43's initial care plan. During a telephone interview on 10/4/2024 at 1:15 pm with MDS Coordinator B, she said that Resident #43 should have had a care plan to address skin issues and the potential negative outcome could be skin breakdown, if not care planned. She confirmed using the RAI Manual for care plans. Record review of the facility's Care Planning Nursing Policies and Procedures last revised June 2019, revealed the comprehensive care plan is developed within seven days of the comprehensive assessment for each resident by the interdisciplinary team. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 5 of 32 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 10/24/2024 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)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for two of six residents reviewed (Residents #60 and #155) for pressure ulcers. Residents Affected - Few 1.The facility failed to provide resident with an air mattress bed as ordered by the physician from when he was re-admitted to the facility on [DATE] until the order was placed on 10/04/2024. 2.The WCN did not provide wound care to Resident #155 by cleaning the pressure wound and patting dry as ordered by the physician. This failure could place residents at risk for worsening of existing wounds or development of new pressure ulcers. Findings included: 1. Record review of Resident #60's Facesheet dated 10/01/2024 revealed Resident #60 was a [AGE] year-old male who admitted to the facility on [DATE]. His medical diagnoses included but not limited to pressure ulcer of sacral (large, triangular bone that forms the base of the spine and the back wall of the pelvis) region, unspecified stage, person injured in unspecified motor-vehicle accident, nontraffic, pathological fracture (when force or impact does not cause the break to happen), hip, infection following a procedure, deep incisional surgical site, acute posthemorrhagic anemia, anemia, major depressive disorder, recurrent, moderate, epilepsy, pressure ulcer of unspecified hip, unspecified stage, other muscle spasm, contracture, right knee, and contracture, left knee. Record review of Resident #60's Quarterly MDS dated [DATE] reflected a BIMS (with 15 being the highest cognitive function) of 99 BIMS indicating that resident was unable to complete the interview. The annual MDS dated [DATE] revealed a BIMS, a measure of cognitive function, with 15 being the highest cognitive function, score of 14 which reflected intact cognition. Record review of Resident #60's Care Plan dated 07/25/2024 revealed Focus: PAIN: Resident was at risk for episodes of increased pain/discomfort and injury AEB, Dx chronic pain, Dx Muscle spasms, Stage 4 wound Date Initiated: 08/17/2022 Revision on: 02/15/2023. CONTRACTURES: Resident had contractures and was at risk for skin break down, increased pain to affected areas and further worsening of contracted areas. Date Initiated: 05/26/2023 Revision on: 05/26/2023. PRESSURE WOUNDS: Resident had pressure wound(s) and was at risk for further skin break down, infection, worsening of existing pressure wounds, new pressure wound formation --Sacral stage 4 pressure wound --Left medial (midline of the body or the median plane) foot stage 4 Date Initiated: 08/17/2022 Revision on: 12/11/2023. ADL SELF CARE DEFCITS: Resident had ADL self-care deficits and is at risk for further decline in ADL functioning and injury AEB, Hip fracture (Fx), generalized weakness, sacral stage 4 pressure wound Date Initiated: 08/17/2022 Revision on: 08/17/2022. ANTICOAGULANTS: Resident was receiving anticoagulant therapy and was at risk for increased bleeding, bruising, etc. Date Initiated: 08/17/2022 Revision on: 08/17/2022. Record review of Resident #60 Braden Score dated 08/06/2022 COMMUNICATION Questions: 1.a Date 08/05/2022 1b. Details (Who, how, what and by whom?): MD W to assess, wound to give treatment orders. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 6 of 32 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 10/24/2024 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 08/05/2022 2b. Details (Who, how, what and by whom?): Resident was self (own representative) 3. Special equipment/Preventative measures (i.e. gel mattress/pad, special bed/Mattress, side rail pads etc.), air mattress 4. Resident is on turning and repositioning routine, first eval. Record review of Resident #60's Wound Care Evaluation dated 02/22/2023 revealed resident's Support Surface Bed Group 2 (alternating-pressure mattresses, low-air-loss mattresses and mattress overlays are indicated for use as a prevention or treatment for pressure ulcers, bedsores and other types of skin tissue breakdown). Record review of Resident #60's Weekly Wound Observation dated 08/06/2024 revealed resident Special Equipment/Preventative measures (i.e. gel mattress/pad, special bed/Mattress, side rail pads etc.) air mattress, stage IV pressure sore to the sacrum area, first observation. 12cm length, 4cm width, 0.3cm depth, 20% slough tissue present (yellow, tan, white, stringy), and granulation tissue present (beefy red). Record review of Resident #60 Progress Notes dated 02/03/2023 at 07:14 AM drafted by NP B revealed: Monthly exam Patient seen in bed resting. sleepy, arousable; stated his pain is manageable with current pain med regimen. he has stage 4 sacral wound, seen by wound care this morning; notes reviewed. Stage 4 chronic sacral wound- wound care following; seen today-2/3/23- notes reviewed; follow recommendations-Off-load wound; Reposition per facility protocol; Turn side to side and front to back in bed every 1-2 hours if able; Group-2 mattress; Vascular consulted. Plan of care discussed with the nurse and patient and patient. Plan of care also discussed with MD K. Record review of Resident #60 Progress Notes dated 08/12/2024 at 09:45 AM drafted by NP C. Stage 4-chronic sacral wound- wound care MD W was following; wound care last seen on-8/8/23- notes reviewed; follow recommendations-Off-load wound; Reposition per facility protocol; Turn side to side and front to back in bed every 1-2 hours if able; Group-2 mattress. Record review of Resident #60 Progress Notes dated 09/03/2024 at 11:53 AM drafted by NP B. Stage 4-chronic sacral wound- wound care MD was following; wound care last seen on - 08/08/2023- notes reviewed; follow recommendations-Off-load wound; Reposition per facility protocol; Turn side to side and front to back in bed every 1-2 hours if able; Group-2 mattress. Record review of Resident #60 Progress Notes dated 09/04/2024 at 11:50 AM drafted by NP B. Stage 4-chronic sacral wound- wound care MD was following; wound care last seen on - 08/08/2023- notes reviewed; follow recommendations-Off-load wound; Reposition per facility protocol; Turn side to side and front to back in bed every 1-2 hours if able; Group-2 mattress. Record review of Resident #60 Progress Notes dated 09/11/2024 at 09:00 AM drafted by NP B revealed: Stage 4-chronic sacral wound- wound care MD K was following; wound care last seen on 08/08/2023 notes reviewed; follow recommendations-Off-load wound; Reposition per facility protocol; Turn side-to-side and front to back in bed every 1-2 hours if able; Group-2 mattress. Record review of Resident #60's Progress Note dated 09/10/2024 at 12:34 PM revealed: Orders Administration Note Text: Stage 4 sacrum: Active 7/28/2023 22:30 7/28/2023. Record review Resident #60's Braden Scale - Predicting Pressure Score Risk dated 09/24/2024, revealed Mild Risk: (risk scale 6 through 23, with 6 being highest risk), score 17 which reflected mild risk. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 7 of 32 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 10/24/2024 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #60 Braden Score dated 10/01/2024 revealed COMMUNICATION. 1a. Date 10/03/2024 1.b Details (Who, how, what and by whom?): MD W on call service phoned, awaiting call back. noted MD K services due to patient refusals and non- compliance. 2a. Date Family/ Notified/Last updated: 10/03/2024 2b. Details (Who, how, what and by whom?): Resident aware 3. Special Equipment/Preventative measures (i.e. gel mattress/pad, special bed/Mattress, side rail pads etc.) air mattress 4. Resident is on turning and repositioning routine. Record review Resident #60's Braden Scale - Predicting Pressure Score Risk dated 10/01/2024 revealed Mild Risk: (risk scale 6 being highest risk through 23 being lowest risk), score 17 which reflected mild risk. Record review of Resident #60's Weekly Wound Observation dated 10/03/2024 revealed resident Special Equipment/Preventative measures (i.e. gel mattress/pad, special bed/Mattress, side rail pads etc.) air mattress. Pressure Sore Stage: stage IV to the sacrum area, size: 2cm length, 4cm width, 0.2cm depth, 20% slough tissue present (yellow, tan, white, stringy), and 40% (considered to be in the early or partial granulation stage) granulation tissue present (beefy red) and 60% (considered final stages) epithelial (thin layer of skin that covers internal and external surface of the body). Record review of Resident #60's Physician Order dated 10/04/2024 at 08:21 AM from MD K revealed, Order Summary/Description: LOW AIR LOSS MATTRESS - PROMOTE WOUND HEALING Ensure Mattress is in place and working all shifts. During an observation and interview on 10/01/2024 at 03:38 PM Resident #60 stated he has sores on his bottom since he had admitted and pointed to a torn and ripped regular mattress laid to the side of his bed. He stated that he was lying on the wrong mattress the whole time he had been admitted and finally received the correct mattress of which he was currently lying on. He stated when he returned to his room a week or so ago and he finally received a new mattress after years of complaining about the old mattress being uncomfortable, worn and torn. Resident was observed sitting 45-degrees upright with both legs bent at the knee. Resident appeared to have had swollen reddish legs with swollen peeling feet. Resident stated he was in constant pain when lying on the old mattress. During an interview on 10/03/2024 at 01:20 PM, the DON stated Resident #60 received a mattress change when he returned from his last hospital visit on 09/10/2024. She stated he was on a regular mattress and received the same regular mattress, from her knowledge. She stated that the LVN E recommended resident receive a new mattress. The LVN E received the order from MD K and the mattress was obtained and placed. She was unaware what the Group 2 Mattress indicated on the resident's physician order. She stated she would ask NP B what Group-2 Mattress means. She stated the benefit of a resident with sacrum pressure wounds having an air mattress provide the resident pressure reduction flexibility, offload parts of body, reduces skin tears and breakdowns for patents that do not move allot. She stated they were having trouble getting him up to change the mattress as he refused patient care often. During an interview attempt on 10/03/2024 at 10:56 AM, to MD K was left a message for a return call back. During an interview attempt on 10/03/2024 at 10:59 AM, NP B was left a message for a return call back. During an interview on 10/03/2024 at 11:17 AM, the LVN E stated her first day with the facility was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 8 of 32 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 10/24/2024 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 09/24/2024. She stated in her role she completed wound assessments and documented notes as to whether resident had wound infections and/or behaviors and if an air mattress was recommended. She stated her assessments were sent to the resident's physicians for review. She stated she was unaware what Group-2 mattress meant on Resident #60's wound care evaluations, but it would more than likely had been determined by the resident's ability, capabilities and the type(s) of wounds measured by the Braden Scale Scorer. She stated she had just began providing wound care to Resident #60 last week and was not aware when he received a mattress change. During an interview on 10/14/2024 at 03:11 PM, ADM B stated she was unaware of the type of mattress Resident #60 was ordered to receive. She stated the resident never rose concerns with a mattress since she had been at the facility. 2. Record review of Resident #155's face sheet, dated 09/30/2024, revealed a [AGE] year-old male with an admission date of 09/09/2024. His diagnoses that included: gunshot wound, paraplegia, sacral (area at the bottom of the spine) and sacrococcygeal (area between the bottom of the spine and the tailbone) region stage 4 ( a full -thickness skin loss that extends into the deep tissues, including muscle, tendons, ligaments cartilage or bone), schizoaffective disorder- bipolar, acute embolism and thrombosis of deep veins of right upper extremity muscle wasting and atrophy, deconditioning, immobility and bowel ostomy (a surgical procedure where an opening is created from the bowel to the body's surface so that waste can be collected directly from the body to a bag). Record review of Resident #155's admission MDS assessment, dated 09/18/2024, revealed Resident #155 BIMS was 12 score indicating moderate cognitive impairment. Resident #155 required limited to extensive assistance with all ADL's and pressure ulcer treatment. Record review of Resident #155's wound assessment form dated 09/30/24 reflected 9/30/24 had the following orders for their wounds: -9/30/24 LEFT HIP - Stage 4 - Cleanse with normal saline, pat dry lightly pack wound bed with 4X4 inch GAUZE soaked with DANKINS (type of solution) cover with pads, secure with TAPE DAILY and PRN if soiled wet or falling off every day shift for wound care. LEFT ISCHIUM (ischium being the lower and back region of the hip bone) - Stage 4- Cleanse with normal saline, pat dry lightly pack wound bed with 4X4 inch Gauze soaked with DANKINS cover with pads secure with TAPE DAILY and PRN if soiled wet or falling off every day shift for wound care RIGHT ISCHIUM - Stage 4 - Cleanse with normal saline, pat dry lightly pack wound bed with 4X4 inch Gauze soaked with DANKINS cover with pads secure with TAPE DAILY and PRN if soiled wet or falling off every day shift for wound care SACRUM - STAGE IV - Cleanse with normal saline, pat dry lightly pack wound bed with 4X4 inch Gauze soaked with DANKINS cover with pads secure with TAPE DAILY and PRN if soiled wet or falling off every day shift for wound care Observation of Resident #155's wound care treatment on 10/02/24 at 11:08 AM, revealed the Wound Care Doctor was at the facility. LVN C and Wound Care Doctor entered Resident #155's room, donned PPE and clean gloves. LVN C took off Resident #155's soiled dressing at his sacral pressure ulcers. The Wound Care Doctor measured the sacral pressure ulcers and then removed his PPE, washed his hands and left the room. The Wound care doctor asked LVN C to dress the pressure ulcers. Resident #155's foley (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 9 of 32 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 10/24/2024 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few catheter was on the bed during wound care. LVN C donned cleaned gloves, soaked a 4 x 4 inch gauze pad with Darkin's solution and placed it on the wounds but not clean the wound with normal saline and pat dry. LVN C then applied pads on the all the wounds and taped it. Record review wound care dated 10/02/24 revealed the physician did the measurement of sacral pressure ulcer which reflected the following: LEFT ISCHIUM - STAGE IV: Length 5.5 CM, width 4 CM and depth 0.5cm RIGHT ISCHIUM - STAGE IV: Length 3.5 CM, width 2.5 CM and depth 0.5cm HIP - STAGE IV : Length 5 CM, width 3 CM and depth 1cm SACRUM - STAGE IV - Length 5 CM, width 7.5 CM and depth 0.5cm Interview with LVN C on 10/02/24 at 2:41 PM regarding wound care she just completed, she said she thought the wound doctor had cleaned the four pressure ulcers and was only asking LVN C to place dressings on them. She said not cleaning the wound could prevent the wound from healing as expected. Interview on 10/02/24 at 3:22 PM with the DON regarding pressure ulcer treatment done by LVN C, the DON said that LVN C started working at the facility four days ago. The DON also said sbe will start retraining LVN C on wound care and doing random monitoring of LVN C doing wound care treatments. The DON said not cleaning the wound could slow down the healing process and cause the resident to develop an infection. Further interview with the DON on 10/03/2024 at 4:20 PM, the DON stated her expectation was for the nurses to follow physician orders. She stated not following physician orders could potentially affect the resident's health. She would have and in-service and monitor the licensed staff. Record review of Physician Orders policy last revised on January 2024: -Purpose: To establish a standardized process for receiving , processing and documenting physician orders in a nursing home setting to ensure resident safety, compliance aand quality of care. Record review of the facility policy on Resident Rights was reviewed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 10 of 32 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 10/24/2024 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents with incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #155) reviewed for incontinent care. -The facility failed to ensure LVN C did not leave Resident #155's foley catheter ( (is a sterile tube that is inserted into your bladder to drain urine), on the bed with urine in the bag during pressure ulcer treatment. This failure could place residents at risk for pain, infection, injury, and hospitalization. Findings included: Record review of Resident #155's face sheet, dated 09/30/2024, revealed a [AGE] year-old male with an admission date of 09/09/2024. His diagnoses that included: gunshot wound, paraplegia, sacral and sacrococcygeal region stage 4 ( a full -thickness skin loss that extends into the deep tissues, including muscle, tendons, ligaments cartilage or bone), schizoaffective disorder- bipolar, acute embolism and thrombosis of deep veins of right upper extremity muscle wasting and atrophy (a clinical condition where blood clots form in the blood vessels of the right upper leg, leading to partial or complete blood flow blockage and resulting in loss of strength in the muscles), deconditioning (decline in physical function), immobility, and bowel ostomy (a surgical procedure that creates an opening in the abdominal wall to allow waste to go from the instestines to exit the body due to bowel damage or dysfunction). Record review of Resident #155's admission MDS assessment, dated 09/18/2024, revealed Resident #155's BIMS score was a 12, indicating moderate cognitive impairment. Resident #155 required limited to extensive assistance with all ADLs, pressure ulcer treatment, and had an with indwelling catheter and ostomy. Record review of Resident #155 's care plan, dated 09/09/24, reflected, . The resident hads an ADL self-care deficit .Interventions .Personal hygiene and Toilet use- Resident is totally dependent . Resident #155 was also care-planned for a foley catheter, with interventions including following physician orders for catheter insertion, changes and maintenance. Review of Resident #155's Physician orders from 09/09/2024 through 09/30/2024 reflected orders for the following: -Foley Catheter monitoring with a start date of 09/11/2024 -Foley Cathter urinary output with a start date of 09/11/2024 -Foley Catheter cleansing and perineal hygiene daily and as needed if soiled, using a catheter securing device with a start date of 09/11/2024 -Foley Catheter flushing with 10 cc of normal saline every night shift and change catheter monthly and as needed with a start date of 10/11/2024 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 11 of 32 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 10/24/2024 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #155's MARs and TARs from 09/09/2024 through 09/30/2024 reflected no evidence of Foley catheter care, Foley catheter monitoring, Foley catheter output. Observation on 10/02/24 at 11:08 AM, revealed wound care doctor was in the facility. Wound care doctor and LVN C came into Resident #155's room, donned PPE and clean gloves. The Foley catheter was on Resident #155's bed during wound care treatment with about 350 cc of urine in the bag. In an interview with LVN C on 10/02/24 at 2:41 p.m., she was asked if the Foley was supposed to be on the bed during pressure ulcer treatment. LVN C said she was not sure who placed the Foley catheter on the bed, and she knew placing the catheter on the bed could cause urinary tract infection . Review of the facility's policy titled Catheter Care, revised February 2024 revealed, .Catheter Management: Positioning: Ensure the catheter bag is positioned below the level of the bladder to allow for proper drainage and avoid reflux of urine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 12 of 32 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 10/24/2024 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)

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 (Resident #37) residents reviewed for intravenous fluids. Residents Affected - Some - The facility failed to ensure Resident #37 had physician orders and care plan in place for monitoring and dressing change of Resident #37's PICC line (Peripherally Inserted Central Catheter, a tube inserted through a vein in the arm which passes to the larger veins near the heart and used to deliver medications, liquid nutrition or other treatments) from when Resident #37 was readmitted from the hospital with a PICC line on 9/09/2024 to 10/2/2024 when the NP put in an order for the PICC line to be discontinued. -The facility failed to ensure Resident #37 's PICC line was removed after completion of IV antibiotics which ended on 09/19/24. -The facility failed to ensure Resident #37 's dry dressing was changed every 5 to 7 days per facility policies and procedures, including orders for monitoring the site. An IJ was identified on 10/04/2024. The IJ template was provided to the facility on [DATE] 12:47pm. While the IJ was removed on 10/06/2024 at 11:47am, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility need to evaluate the effectiveness of the corrected system. This deficient practice could place residents at risk of serious harm, injury or death by leaving the PICC line in longer than necessary and exposing residents to infections in the blood stream and serious illness. Findings included: Record review of Resident #37's face sheet dated 10/03/2024 revealed he was a [AGE] year-old male that was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of acute cystitis with hematuria (a bladder infection that may cause blood in the urine), anemia(low red blood cell count), hypotension (abnormally low blood pressure), colostomy (a surgical opening for the colon in the abdomen which provides an alternative channel for feces to leave the body), intestinal obstruction, and schizophrenia (a serious mental health condition which may include hallucinations, delusions and disorganized thinking and behavior) . Record review of Resident #37's hospital discharge records dated 9/9/24 revealed Resident #37's midline placement (a catheter placed in a vein used to deliver medications and other treatments quickly to the body) date was 09/05/24. Further review revealed Resident #37 was ordered meropenem (MERREM) 500 mg intravenously every 8 hours for 9 days with a start date of 9/10/2024 and a stop date of 9/19/2024. He had a transfer diagnosis of hematuria (blood in urine). Record review of Resident #37's September MAR revealed he received the medication every shift as ordered starting 09/10/2024 at 11:00pm to 09/19/2024 at 3:00pm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 13 of 32 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 10/24/2024 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)

F 0694 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of Resident #37's physician's orders last updated 10/03/2024 and care plan last revised 09/11/2024 revealed no documented orders or instructions for maintenance of midline and dry bandage. Record review of Resident #37's physician's progress notes dated 9/11/24 revealed, Patient is being seen today to follow up on hospitalization. Patient is on IV abx (antibiotics) for 9 days for sepsis . Observation on 10/1/24 at 5:10 p.m., revealed Resident #37 lying in bed and , had a PICC line in his left arm, double lumen (a catheter which splits into two tubes, with each tube being used to take or give blood products and the other used for medication or IV fluids) with two tape dressings cover it one on the other. The first dressing was dated 9/5/24 which was when Resident #37 was in the hospital and the second dressing on top was used to secure the first dressing and was not dated. Both dressings and tape were brownish in color. Resident #37 was not interview-able and had a representative at bedside. Interview with the DON on 10/2/2024 at 2:54pm, nurses should ensure residents with PICC line have physician orders for it. PICC line dressings should be changed every 5 to 7 days and that nurses should observe the PICC line site every shift to ensure no redness, drainiage, not be hot to the touch. Interview with the MDS Coordinator A on 10/3/24 at12:28p.m., she was not aware of Resident #37's PICC line. She always assessed a resident with PICC on admission, documenting how the PICC line site is and checking for infection. She said currently the facility had 2 residents with a PICC. Interview with LVN B on 10/03/2024 at 11:52am, she stated that nurses were to follow physician's orders for residents with PICC llines. LVN B stated that dressing changes should be done every 5 to 7 days and as needed and that nurses should inform the doctor when a resident's antibiotic therapy was completed. LVN B said sometimes a PICC Line was not removed immediately after antibiotic therapy completion because the resident's physician ordered more labs before discontinuing the PICC Line, but that she would continue to monitor and flush the PICC line every shift until it is discontinued. She said she never worked with Resident #37. Interview with LVN C on 10/03/2024 at 12:00pm, he stated that when a resident is admitted to the facility with a PICC Line, they should already have physician's orders for it, including dressing changes. LVN C stated that after a resident completes antibiotic therapy, the physician should be notified. Interview with LVN A on 10/03/2024 at 3:00 pm, LVN A stated when a resident was admitted the nurse was supposed to call the physician do all the paperwork such as verifying and entering medications and treatments into the MAR. Interview with NP A on 10/3/2024 at 4:32pm, she stated that when a resident is admitted from the hospital the NP will review medications that day and review the resident's clinical notes the next on-site visit. NP A stated she did not put any orders for the resident's PICC line to be discontinued nor for dressing changes it, but that it was her fault that the orders were not put in Resident #37's MAR and it was her responsibility to do that when her residents were admitted with a PICC line. She stated that nurses are to update her if there is changes in condition and to questions her orders, but that they did not do so. NP A stated that PICC lines would be discontinued after the treatment is completed and after all labs are done to confirm it can be removed. She stated the facility called (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 14 of 32 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 10/24/2024 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)

F 0694 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some her on 10/2/24 to get the PICC line discontinued. NP A said that risks for a resident not having their dressing changed per physician's orders or standard practice is that it could cause infection and sepsis. Interview on 10/3/24 at 5:04pm with the ADON and Administrator, the ADON said that the PICC line and dressing change should be administered according to physician's orders and that nurses were expected to let the doctor know when the antibiotics were completed. The ADON said that when a resident completed their antibiotics, the nurse should call the physician to see if the order should be discontinued, if labs needed to be drawn or if the antibiotics need to be continued. The Administrator said that staff should have followed physician's orders. The ADON said that having the dressing on since 9/5/24 would be an infection control concern and it could pose a risk of bacteria with a dressing on that long without being changed and cleaned. The Administrator said the risk due to leaving the bandage on for that amount of time is related to infection control . An IJ was identified on 10/04/2024. The facility was notified of the IJ on 10/04/2024 at 12:47pm with the Interim Administrator, RNC and DON present. The IJ template was provided to the facility on [DATE] 12:47pm and a POR was requested by email to the Interim Administrator, RNC and DON. The following Plan of Removal was submitted by the facility and accepted on 10/04/2024 at 5:45pm. Allegation F694: [Facility Name] - IJ Plan of Removal F694 10/4/2024 The facility failed to ensure a peripherally inserted central catheter (PICC) (a thin, flexible tube that is inserted into a vein in the upper arm and ends in a large vein near the heart) used to administer parenteral fluids and antibiotics had an order how to cleaned and discontinued consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences. On October 2, 2024, Resident #37's PICC line was assessed by the Director of Nursing (DON), with no adverse effects or signs or symptoms of infection noted. A physician's order was obtained for the removal of the PICC line, and PICC line was discontinued without adverse effects. The Physician ordered lab work on 10/3/24 and results were noted with no adverse findings. On October 2, 2024, all other residents with central lines were assessed by the Director of Nursing to ensure an up-to-date dressing, active order sets to include monitoring, flushes, dressing changes, orders to obtain central lines after IV therapy is completed, and central line specific care plans. No adverse findings were noted. The Administrator and DON informed the Medical Director of the Immediate Jeopardy situation on October 4, 2024, through an AD Hoc QAPI meeting. The Regional Nurse Consultant provided 1:1 education with the DON on 10/2/24 on providing oversight with residents with central lines and ensuring compliance with central line policies and procedures to include active orders for monitoring central line site, flushing the central line, central line dressing changes, and obtaining orders to remove central lines after IV therapy is completed. The Director of Nursing initiated in-services with licensed nurses on 10/2/24 on and ensuring compliance with central line policies and procedures to include active orders for monitoring central line (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 15 of 32 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 (X3) DATE SURVEY COMPLETED A. Building 10/24/2024 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)

F 0694 site, flushing the central line, central line dressing changes, and obtaining orders to remove central lines after IV therapy is completed. Education will be completed on 10/4/24. Licensed Level of Harm - Immediate jeopardy to resident health or safety Nurses will be educated prior to their next shift: including PRN employees or new hires. Residents Affected - Some After the IJ was called out on 10/4/24, the Director of Nursing conducted 100% rounds on residents with central lines and compliance was noted with policies and procedures. The Administrator reviewed the Central Line Policies and Procedures on 10/4/24 and no changes were required. The charge nurse will input and complete orders for residents who obtain or admit with a central line and will be validated in clinical morning meeting by nurse leadership. The clinical morning meeting will include reviewing high risk residents to include residents with central lines and ensuring compliance with central line policies and procedures (orders and care plans). DON Inservice nurse leadership on 10/4 on the above process; The charge nurse will input and complete orders for residents who obtain or admit with a central line. Completion date 10/4. Record review of Physician Order policy last reviewed January 2024 revealed that all physician orders must be verified by the receiving nurse for accuracy and upon receipt the nurse will enter the order into the electronic health record. Nursing staff will review physician orders and follow up on any discrepancies or unclear orders with the prescribing physician. Record review of the facility's Nurses' Infusion Manual for Long Term Care Facilities last updated 05/16/2022 revealed a dressing changing must be done every 7 days or sooner if compromised adn be monitored for signs and symptoms of compllications from infection like swelling, redness or pain. Record review of the facility's Central Line policy last revised January 2024 revealed that nursing staff are not obtain physician orders to remove the central line once IV therapy is completed. [Signed by Interim Administrator, 10/4/2024] Monitoring the Plan of Removal for Effectiveness as follows: Observation on 10/05/2024 at 12:45pm of Resident #10 revealed the resident had a left peripheral IVF hep-lock single lumen (a single catheter line placed in a vein on a resident's left side of the body that contains a medication called heparin used to prevent blood clotting), the site was cleaned with no redness, dressing infiltration, odors, or warmth. The dressing on the site was dated 10/03/24. Observations and record review of other residents with a PICC line revealed: Record review of Resident #7's orders revealed nurses were to monitor the PICC line site every shift, midline dressing change every 5 days and as needed, a midline flush 10 millilters of Normal Saline every shift. Observation of the resident on 10/05/2024 revealed Resident #7 was sitting in the dining area eating lunch with their PICC line to their left upper arm intact. Resident #7 had a left upper arm IVF hep-lock double lumen, the site was clean with no redness, dressing infiltration, odors, or warmth. Dressing on the PICC line site was dated 10/02/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 16 of 32 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 10/24/2024 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)

F 0694 Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #155's orders revealed nurses were to monitor the midline every shift, midline dressing changes every 5 days and as needed, a midline flush of 10 milliliters of Normal Saline every shift. Observation of Resident #155 on 10/05/2024 revealed the resident was sitting in the dining area eating lunch with the PICC line to their upper arm intact. Resident #115 had left upper arm IVF hep-lock double lumen line, the site was clean with no redness, dressing infiltration, odors, or warmth. Dressing on the PICC line site was dated 10/02/24. Residents Affected - Some Interview with LVN I on 10/04/2024 at 4:30pm, she said she only took care of Resident #37 when he was admitted . LVN I said she was supposed to document in the TAR that Resident #37 is to have his PICC line inititaed but that she forgot. LVN I said that any nurse, including the nurse on the next shift could have obtained orders and entered them in Resident #37's chart. LVN I said she had not worked at the facility since that day when she admitted Resident #37. Interview with RN G on 10/05/2024 at 1:15pm, she said that she received in-services a few days ago for PICC line. RN G said she was educated on making sure residents with a PICC line had orders from their physician for monitoring, maintaining the dressing, which should be changed every 5-7 days depending on the physician orders , and to notify the physician when the residents get to the facility and when antibiotics were completed so that the nurse could place an order to discontinue the PICC line. Interview with RN A on 10/05/2024 at 1:30 pm, she said that she received in-services a few days ago for PICC line. RN A said she was educated on making sure residents with a PICC line had orders from their physician for monitoring, maintaining dressing which should be changed every 5-7 days depending on the physician orders, and that she should notify the physician when the residents get to the facility and when antibiotics are completed so that the nurse can place an order to discontinue the PICC line. Interview with the DON on 10/05/2024 at 2:00pm, the DON said the nurses were not doing what they should have, which included the documenting residents with PICC line and to check the line every shift and flush the line, ensure the site is clean, and getting Physician Orders for removal of PICC line after antibiotics are completed. The DON said she immediately started in-services on PICC line for the nurses. Interview with RN E on 10/05/2024 at 8:30pm, she stated she worked every other weekend as a weekend supervisor. RN E said she had in-services and also conducted in-services for other nurses, which included making sure staff get physician orders for residents with PICC lines including monitoring the line site and maintenance of the line, notifying the physician when antibiotics are completed, contacting the physician with labs and when to discontinue the PICC line. RN E stated that staff are to notify the resident's physician if they do not see PICC line orders. RN E also said that all care provided to a resident for their PICC line should be documented in their MAR. Interview with LVN B on 10/05/2024 at 8:42pm, she said that she received in-services a few days ago for PICC line. LVN E said she was educated on making sure residents with a PICC line have orders from their physician for monitoring and changing the resident's dressing every 5 to 7 days depending on the physician orders, and to notify the physician when the residents get to the facility and when antibiotics are completed so that the nurse can place an order to discontinue the PICC line. Interview with LVN D on 10/05/2024 at 9:47pm, she stated that she had been at the facility for a year and works night shifts. She stated she received educations on PICC and IV lines, making sure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 17 of 32 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 10/24/2024 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)

F 0694 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some residents have orders after having a PICC line placed, calling the physician and verifying that residents have orders for the PICC line, monitoring for signs and symptoms of infection, and dressing changes which are every 5 days. LVN D said she also received education on informing the physician when the antibiotics are completed and make sure that orders are put in for PICC line to be discontinued. LVN D said that after treatment is completed and before being discontinued, nurses should still observe for any changes in the PICC line site and to flush the line every shift and to document anything done for the PICC line in the resident's chart. Interview with RN D on 10/05/20234 at 9:54pm, she stated that she had been with the facility for more than a year and works night shifts. She stated that she received in-services on PICC line on 10/04/2024, which included making sure residents with a PICC line have orders for dressing changes every 5-7 days depending on the physician orders, flushing before and after medication and every shift, monitoring the PICC site for signs of infection and reporting any changes to the physician, and to inform the physician when the resident's antibiotics are completed and to get an order to discontinue the PICC line per physician orders. RN D stated that after a resident is admitted , nurses are to verify PICC line orders with the resident's physician, the nurse then assess the PICC line site to see where and when the line was placed, make sure there are orders for signs of infection, dressing changes, how often to flush the line, checking fluids through the lines, and documenting PICC line care in the resident's MAR. An IJ was identified on 10/04/2024. The IJ template was provided to the facility on [DATE] 12:47pm. While the IJ was removed on 10/06/2024 at 11:47am, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility need to evaluate the effectiveness of the corrected system. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 18 of 32 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 10/24/2024 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)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 that residents who needs respiratory care, including tracheotomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of two residents reviewed for tracheotomy care (Resident #200). Residents Affected - Few -The facility failed to ensure RN G used sterile technique during tracheotomy care and suctioning for Resident #200. This failure could place residents with a tracheotomy requiring suctioning at risk for respiratory infections, hospitalizations, and a decline in their quality of life. Findings included: Record review of Resident #200's face sheet dated 10/2/2024 revealed a [AGE] year-old male resident was admitted to the facility on [DATE]. Resident #200 had diagnosies of Acute Respiratory Failure with Hypoxia (occurs when the body doesn't have enough oxygen in its tissues) and alcoholic cirrhosis of liver with ascites (ascite being abnormal fluid buildup), abnormal posture, esophageal varices with bleeding (enlarged veins in the esophagus with bleeding), alcohol abuse, and other seizures, metabolic encephalopathy (alteration in consciousness caused by an underlying condition, which can lead to confusion, memory loss and loss of consciousness). Record review of Resident #200's MDS assessment dated [DATE] revealed the BIMS assessment was blank and mental status assessment found he had short-term and long-term memory/recall ability problems and was severely cognitively impaired. Record review of Resident #200's Care Plan reflected Resident #200 had ADL self-care deficits and was at risk for further decline in ADL functioning and injury. It also reflected Resident #200 had a tracheostomy and was care-planned for routine equipment maintenance and changes as indicated, following physician orders related to oxygen administration, medication administration, labs, and encouraging resident to keep head of bed elevated. Record review of Resident #200's Physician Orders reviewed 09/28/2024 revealed the following: -Order date: 09/28/2024 - Tracheostomy Care cuffed flex Shiley 6 with disposable inner cannula) as indicated every 12 hours and PRN. Trach Care: Suctioning,every shift Suction tracheostomy tube as needed to clear airway. Document # of Suctions Performed During Assigned Shift. Notify MD of any abnormalities. Observation on 10/2/2024 at 11:00 am revealed Resident #200 was in bed with audible moist breath sounds. RN G donned gloves and set up a clean field on top of the bedside table, checked Resident #200's oxygen saturation which was 98%. RN G removed her dirty gloves and picked up a Trach Care Kit. RN R opened the sterile Trach Care Kit, then picked up and donned the sterile gloves in the kit, and suctioned Resident #200 several times. She changed into a new pair of gloves without washing her hands or using hand sanitizer in between. She grabbed the sterile suction catheter kit tray with the inner canula, opened it, then donned sterile gloves again without washing her hands. RN G then removed Resident #200's used inner cannula and replaced it. RN G cleaned the surrounding trach area using (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 19 of 32 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 10/24/2024 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)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the sterile 4x4 inch gauze and dipped the gauze in the normal saline three different times without changing gloves or performing hand hygiene during the cleaning and changing of tracheostomy tubes. In an interview on 10/02/2024 at 1:30 PM, RN G stated she did not wash her hands during trach care or during suctioning. She stated she should have used sterile technique throughout, and she was recently in-serviced on tracheostomy care but could not recall the date of the in service. RN G did not disclose why she failed to use sterile technique. She stated she was working with Resident #200 for the first time during the observed trach care. RN G stated that her observed technique placed the resident at risk for a respiratory infection. In an interview on 10/04/2024 at 5:00 PM, the DON stated that RN G had not been in-serviced on tracheostomy and that RN G started working 3 days ago. The DON stated that RN G should have used sterile techniques during tracheostomy care. The DON stated that using the technique RN G used could have placed the resident at risk for an infection. The DON stated that the facility's scheduled respiratory therapist was usually responsible for providing respiratory care, but the nurses are trained in the event that the respiratory therapy staff is not available. The DON stated that the respiratory therapy department primarily oversaw the trach care, but she would be working with the respiratory therapy to ensure that nursing staff were held accountable as well. Review of the facility's policy titled Tracheostomy Care revised 11/2022, read Aseptic technique must be used: during cleaning and sterilization of reusable tracheostomy tubes; during all dressing changes until the tracheostomy wound has granulated (healed); and during tracheostomy tube changes, either reusable or disposable. Gloves must be used on both hands during any or all manipulation of the tracheostomy. Sterile gloves must be used during aseptic procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 20 of 32 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 10/24/2024 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)

F 0759 Ensure medication error rates are not 5 percent or greater. 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 pharmaceutical services (including procedures that assure the accurate acquiring, dispensing, and administering of all drugs and biologicals) to meet the needs of 2 of 5 residents (Resident #83 and Resident #205) reviewed for pharmacy services with 5 errors out of 33 opportunities from 2 of 2 staff (MA A and RN A) and a medication error rate of 15%. Residents Affected - Some 1. The facility failed to ensure MA A administered Pantoprazole granules (medicine used to reduce amount of acid in teh stomach) mixed with 10 cc apple juice or applesauce per physician orders and Ferrous Gluconate (medicine used to treat or prevent low blood levels of iron) per physician orders for Resident #83 2. RN A failed to administer the following medications correctly for Resident #205: - Megastrol 40mg/ml oral suspension (medicines used to treat loss of appetite, malnutrition, and severe weight loss in patients with acquired immunodeficiency syndrome (AIDS) by not following pharmacy orders to Shake well -Ferrous Sulfate 325 mg (medicine used to treat or prevent low blood levels of iron) by administering Ferrous Gluconate 240 mg T tablet by mouth instead - Latanoprost 0.005% eyes suspension (medicine used to treat increased intraocular pressure) in the day time instead of at bedtime These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health. Findings included: 1. Record review of Resident #83's face sheet dated 09/27/2024 revealed resident was admitted to the facility on [DATE] and was re-admitted on [DATE]. Resident #83 had diagnoses of sepsis,( a serious condition in which the body responds improperly to an infection) and ,schizophrenia ( a serious mental health condition that affects how people think, feel and behave),and Essential (Primary) Hypertension (high blood pressure that is multi-factorial and doesn't have one distinct cause); and Cellulitis (a bacterial infection that affects the skin). , Record review of Resident# 83's quarterly MDS assessment dated [DATE] revealed a BIMS score of 09 which indicated moderately impaired cognition. It also revealed the resident needed total care assist with ADL with two staffs assistance. Record review of Resident #83's physician's order summary report revealed the following order: order dated 07/8/2023, Ferrous Sulfate Tablet 325 (65 Fe) MG Give 1 tablet by mouth one time a day for anemia (9:00am). order dated 07/8/23 Pantoprazole 40 mg packet mix of 10cc apple juice or apple sauce po (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 21 of 32 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 10/24/2024 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)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Record review of Resident #205's face sheet dated 09/27/2024 revealed an [AGE] year-old male admitted to the facility on [DATE]. Resident #205 had diagnoses of heart failure, respiratory distress, malignant neoplasm, bronchus or lung and peripheral vascular disease (dysfunction of the veins by the lungs), and presence of cardiac pacemaker. Record review of Resident# 205's admission MDS dated [DATE] revealed a BIMS score of 12 which indicated moderate impairment of cognition. It also revealed the resident needed total care assist with ADL with two staffs assistance. Record review of Resident #205's physician's order summary report revealed the following orders: order dated 09/23/2023, Ferrous Sulfate Tablet 325 (65 Fe) MG Give 1 tablet by mouth one time a day for anemia (9:00am). . order dated 09/26/23, Latanoprost Solution 0.005 % Instill 1 drop in both eyes at bedtime. . ordered 9/27/2024 Megestrol Acetate Suspension 400 MG/10MLMegestrol Acetate Suspension 400 MG/10MLGive 10 ml by mouth two times a day for appetite for 30 Day. The bottle indicated for the user to Shake Well. Observation on 09/30/2024 at 8:48am revealed medication administration with MA A for Resident # 83. MA A was observed preparing and administering Resident # 83 medications by giving Resident #83 Ferrous Gluconate 240 mg 1 tablet po instead of Ferrous Sulfate Tablet 325 (65 Fe) MG. MA A also administered and Pantoprazole 40 mg packet mixed with yogurt instead of apple juice or applesauce as instructed by the pharmacist. Mixing Pantoprazole with yogurt can reduce the rate at which the drug dissolves, especially in the first 10 minutes due to yogurts high viscocity (https://www.fda.gov/media/149137/download#:~:text=This%20was%20due%20to%20the,10%20minutes%20in%20PBS% Later observation on 09/30/2024 at 9:06am, RN A was observed administering Megestrol 40 mg/ml/oral suspension 10 mls. RN A opened the top cap of the medication bottle, open the seal on top of the medication container in the plastic bag from the pharmacy, RN A did not shake the bottle before administering the medication to Resident #205. The bottle was labelled Shake Well. RN A also administered Latanoprost Solution 0.005 % at that time, with the solution's label instructing to instill 2 drops in both eyes at bedtime. Interview with MA A on 10/04/24 at 3:22 pm, the surveyor showed MA A the medication blister packet of Pantoprazole 40 mg packet which was labeled to adminster with apple juice or apple sauce. The surveyor also showed MA A the Ferrous Sulfate Tablet 325 (65 Fe) medication label. MA A said for Pantoprazole 40 mg packet, she had told the DON she needed applesauce for the medication and that the DON told her the facility did not have apple sauce or juice and it was fine to use yogurt. MA A said she was sorry for giving Ferrous Gluconate instead of Ferrous Sulfate and that she would be more careful . MA A stated that medications should be administered as ordered by the doctor and tofollow recommendations due to the potential side effects if she did not follow the instructions. MA A said she started working with the facility on 6/25/24 and had not had any medication training. Interview on 10/04/24 at 3:34 PM RN A regarding her administering to Resident #205 Ferrous Gluconate 240mg tablet po instead of Ferrous Sulfate Tablet 325 (65 Fe), and not shaking Megestrol 40 mg/ml/oral suspension 10mls before pouring into the medication cup, and instilling Latanoprost Solution (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 22 of 32 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 10/24/2024 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)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 0.005 % Instill 2 drops in both eyes in teh daytime, she said she was very sorry and was nervous and that she would have to double check the medication. RN A said she knew giving medications not as ordered by the physician could result in residents not getting the benefit of the medication. RN A said she did not receive in-services on medication. In an interview on 10/04/2024 at 5:05 pm, Tthe DON stated that she recently started working at the facility a couple of months ago, but she would be the individual responsible for overseeing and having the pharmacist monitor the staffs during medication administration. The DON stated that all nurses and MA staff had been trained and were knowledgeable of the medication administration policy. The DON stated that additional training would be provided. Record review of RN A's personnel file reflected date of hired was 8/27/24 and there were no medication trainings in her personnel file. Record review of the facility's policy titled Medication and Treatment orders dated November 2014, read Medications shall be administered only upon the written order . The policy did not address administering meds timely and administering all the meds correctly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 23 of 32 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 10/24/2024 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to ensure foods were dated as opened or prepared and discarded after 72-hours (3 days) per facility policy. 2. The facility failed to store food off the floor in the storage room. 3. The facility failed to self-report to the local Department of Health for drain water backup in the kitchen, with less than a one-inch air gap. These failures could place residents at risk of food borne illness and disease. Findings Include: Observation of the facility kitchen in the walk in refrigerator on 09/30/2024 at 8:15 AM revealed the following: 1. A plastic bag of boiled eggs not labeled. 2. A plastic bag of fresh salad not labeled. 3. A plastic bag of shredded cheese not labeled. 4. A plastic bag of sliced American cheese dated open 9/24. 5. A plastic container of green beans dated open 9/29 6. A plastic container of cooked pasta dated open 9/26. 7. A plastic container of Mexican rice dated open 9/25. 8. A plastic container of breaded fish dated open 9/22. 9. Two cases of canned food were on the storage room floor. Observation of the facility kitchen on 09/30/2024 at 8:15 AM revealed the following. 1. Kitchen floor was wet with water near dish machine and 3-sink compartment. 2. Ice machine and dish machine did not have proper air gap of one inch to prevent back flow drain water backup. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 24 of 32 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 10/24/2024 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm 3. There were holes in the ceiling by the dishwashing machine and in the walls near the Dietary Food Service Manager (DFSM)'s office. Observation of the facility kitchen on 10/01/2024 at 8:30 AM, revealed drain water backup on the floor was flowing. Residents Affected - Many In an interview with the DFSM on 09/30/2024 at 8:30 AM, she stated the leftover food stored in the refrigerator should have been used or discarded prior to use by date. She stated the cases of food should be off the floor due to cross contamination. She stated she or the designee were responsible for checking the refrigerator daily for food items that were expiring and should be discarded prior to expiration date. In an interview with the DFSM on 09/30/2024 at 8:30 AM revealed that on 09/28/2024, the kitchen had a drain water backup, and that the Contractor Plumber (CP) fixed the problem. DFSM stated that she did not report the drain water back up to the local health department. She stated that she needed to get maintenance to fix the holes in the ceilings and walls to prevent pest rodents to enter the facility. Observation on Tuesday 10/01/2024 at 8:30 AM revealed the kitchen had another drain water back up. DFSM stated that she would contact the local health department. A local Health Department Inspector (HDI) came within that day and ordered the facility to cease operations, stop preparing, and serving food. All food not sealed at that point in time were to be disposed of immediately. In an interview with HDI revealed that the facility did not self-report the drain water backup the past weekend. She stated that according to Sec. 18-86 City Ordinance section where it stated that the establishment must cease operations in the case of a sewage backup. In an interview with ADM A on 10/23/2024 at 08:42 AM, she stated that on 10/01/2024 she entered the kitchen and observed a large board covering the drain in the dish room area. She stated she lifted the board and observed floor and tiles were removed and the pipes and dirt were exposed. She stated she learned from the Maintenance Director that the plumbing contractor had come out overnight and began repairing and unclogging the drainpipes that were damaged beneath ground. She stated that the facility's kitchen operations were approved for reopening on 10/08/2024 by the HDI. She stated dietary service staff received an in-service on immediately reporting backflow water to maintenance on 10/03/2024 and would receive another 10/23/2024 and ADM A. In an interview with DFSM on 10/23/2024 at 9:20 AM, she stated on 09/21/2024 she first became aware of an issue with the airgap when it backed up in the dish room. She stated the staff immediately stopped washing dishes and notified the maintenance director who called a plumbing contractor. She stated that the dishwasher machine's water had come up from the drain and covered the dish room floor. She stated a plumbing service came in repaired the grease trap on the outside of the building. She stated on 09/21/2024 the facility used paper products the whole day and into the next day until the CP fixed the backflow issue to ensure the backflow had not contaminated any of their eateries. She stated on 09/30/2024 she learned from the state survey team that the airgap was not the required 1.5 inches from the floor. She stated the airgap positioning was low and allowed the potential for easy backflow into the airgap pipe if water levels rose. She stated that she called the Health Department on 09/30/2024 to self-report the airgap and backflow issue. She stated on the morning of 10/01/2024 she seen a large board had been laid over the drain. She learned from the Maintenance Director that the CP's team worked on the pipes overnight and the work was not completed. She stated the board was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 25 of 32 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 10/24/2024 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many laid to allow for the area to dry while also allowing her staff to continue to work in that area. She stated that same morning, the HDI came to the facility and during the walkthrough noticed that the airgap was too low. She stated that the drain cap was off centered and the cylinder block under the cap had fallen over which caused the drain cap to be low and off centered. She stated that the HDI immediately discontinued food service operations in the kitchen, by closing the kitchen. She stated it was her understanding the kitchen was closed for precautionary measures from possible contamination from the airgap backup. She stated she provided an in-service to her dietary staff on 10/01/2024 on the airgap, backflow system, and reporting backflow issues to the Maintenance Director and ADM A immediately. She stated they purchased food and/or prepared food from a sister facility. She stated during that timeframe they purchased disposable eateries, utensils and paper products as well as obtained disposable products from their sister facility. She stated the repairs to the kitchen were completed on 10/03/2024, at which point a team came out and sanitized everything in the kitchen top to bottom, which included deep cleaning scrubbing floors, and throwing out food items that had been opened. She stated once the kitchen was opened on 10/08/2024, they rewashed their dishes and began normal operations which allowed time to serve lunch. She stated her team and her received a reeducation in-service on 10/23/2024 by ADM A on the airgap, backflow system, and reporting backflow issues to the maintenance director and ADM A immediately. In an interview on 10/23/2024 at 9:20 AM, Maintenance Director stated on 09/21/2024, he received notice from the DFSM that that the dish room had experienced water overflow. He stated he reported the overflow to ADM B and CP had been contacted. He stated the CP ran a snake system through the drain line and it was discovered that the grease trap was clogged and needed clearing. He stated the plumbing services did not interrupt any kitchen operations as the grease trap clearing took place on the exterior area of the facility. He stated on the morning of 09/30/2024, he was made aware by the state survey team that the airgap was not measuring at its required height and the airgap had begun backed up in kitchen's dish room. He stated a drainage airgap was required at a minimum vertical distance, to be measured from the lowest point of the indirect water pipe or the fixture outlet to the flood-level rim. He stated the receptor shall not be less than 1-inch (25.4 mm). He stated on the evening of 09/30/2024 the CP returned, reran the snake, found that the water drainpipe was broken, and tree roots had grown into the pipe causing the interruption of water flow. He stated the backflow consisted of water from the kitchen sinks and dish machine. He stated it was considered a part of the grey water sewage line or system. He stated grey water runs from the kitchen sinks, through the dishwasher machine, down the airgap, into the drain system on the dish room floor, under the kitchen floor, and under the concrete in the parking lot about 25-ft to where it reaches the cities mainline. He stated that the toilets do not run into that line. He stated that the toilets run on what was known as a black water sewer line. He stated that the kitchen water runs on the grey water sewer line and the two lines do not meet, cross, or run into the same lines. He stated that on 10/01/2024, the kitchen repairs were still under construction, and kitchen services were discontinued by the HDI from what he understood, due to the airgap repairs. He stated the repairs took over 3-days and required cutting away the dish room flooring and tiles and the concrete in the facility's parking lot. He stated the facility brought food in from a sister facility and catered from local restaurants. He stated he had not spoken to the HDI. He stated there have been no issue with the back flow since the completion of the repairs on 10/03/2024. He stated he was in-serviced on 10/03/2024 on the airgap and paying attention to the inches from the airgap and the floor by ADM A. Interview on 10/23/2024 at 12:18 PM, CP stated that he was hired by the Master Plumber (MP) on 09/21/2024 to unclog the facility's grease trap that had backed up on the outside (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 26 of 32 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 10/24/2024 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many of the building. He stated the grease trap filtered out food particles and had backed up and was cleaned. He stated he provided the facility with an invoiced dated 09/28/2024 for that service. He stated on 09/30/2024, the Maintenance Director rehired him to return to the facility and address a backflow issue, totally separate and unrelated service and repairs from his 09/21/2024 visit. He stated that they ran the snake down the drainpipe and found that there were two old snake heads that had broken off in the line and had clocked and damaged the line. He stated when the kitchen staff ran the garbage disposal it would not allow for the food and the water to flow though causing a backup. He stated it did not even happen each time they ran the garbage disposal, but enough where when particles settled the backflow was created. He stated he reported the findings to the facility who gave them the go ahead to make whatever repairs were needed to correct the problem. He stated that began work on the late evening of 09/30/2024 and was completed on 10/03/2024. He stated the MP prepared a report that was submitted to the Health Department. He stated the backflow was only grey water which accumulated from the kitchen sinks and dishwasher. He stated that the black water sewage was not and could not connect or backup in the kitchen when the airgap, line or drain clogged. Record review of Retail Food Establishment Inspection Report dated 10/01/2024 from Health Department Inspector revealed, Violation Follow-up: Received a call from DFSM in regard to a sewage backup in kitchen. Arrived at the establishment at 11:15 AM. DFSM mentioned that issue had been resolved but noticed sewage backup during inspection . Ice machine in dish room have pipes without 1 inch air gap. These are signs of water backup in dish room, kitchen. By 3-compartment sink and ice machine drains. Licensed plumber must be contacted to inspect plumbing and water quality must be tested. May not operate until repairs are completed, and water quality has been cleared. May only use clean portable water. Must voluntary discard any food prepared onsite today. Will follow-up for final inspection once ready Signed acknowledgment by DFSM. Record review of in-service training dated 10/01/2024 and 10/23/22024 titled: Backflow revealed ADM A provided 1:1 in-service training to DFSM on all things hazardous conditions in the kitchen, reporting all environmental changes immediately, notifying managers of overflow, and ceasing meals until cleared by appropriate parties. Record review of in-service training dated 10/01/2024 and 10/23/22024 titled: Backflow revealed DFSM provided in-service training to dietary staff on reporting environmental changes including broken equipment, and notifying managers of overflow, and ceasing meals until cleared by appropriate parties. Record review of in-service training dated 10/03/2024 titled: Emergency Maintenance Repairs and Concerns revealed ADM A provided 1:1 in-service training to Maintenance Director on reporting all emergency maintenance repairs immediately to the ADM A. Failure to do so can subject you to progressive disciplinary action. Record review of in-service training dated 10/03/2024 titled: Air Gap revealed ADM A provided 1:1 in-service training to Maintenance Director. Record review of Health Inspector Report dated 10/08/2024 revealed: Main initial violations: 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 27 of 32 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 10/24/2024 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm §228.247 (A). A person may not operate a food establishment without a valid permit or license to operate issued by the regulatory authority. (Health Permit expired 9/30/2024 and must be renewed as soon as possible) 2. Residents Affected - Many §228.248 (5) Immediately discontinue operations and notify the regulatory authority if an imminent health hazard may exist as specified under §228.252(a) of this title; 3. §228.252 (a) Ceasing operations and reporting. (1) Except as specified in paragraph (2) of this subsection, a food establishment shall immediately discontinue operations and notify the regulatory authority if an imminent health hazard may exist because of an emergency such as a fire, flood, extended interruption of electrical or water service, sewage backup, misuse of poisonous or toxic materials, onset of an apparent foodborne illness outbreak, gross insanitary occurrence or condition, or other circumstance that may endanger public health. P [12] Corrections needed: 1. §228.66 Food protected from cross-contamination (Food products in walk-in cooler that were exposed to cross contamination from sewer backup and food not sealed must be discarded) 2. §228.146 (c) Backflow prevention, air gap. An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). P [19] (Dish machine and ice machine must have a proper air gap/ these pipes must be replaced) 3. §228.174 (e) (1) (A) Except as specified in paragraphs (2) - (5) of this subsection, outer openings of a food establishment shall be protected against the entry of insects and rodents by: (A) filling or closing holes and other gaps along floors, walls, and ceilings; (Holes in ceiling must be repaired and sealed) 4. §228.114 (c) & §228.173 Nonfood-contact surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. [42] (Kitchen floors must be cleaned and sanitized) 5. §228.173 (a) Cleanability. Except as specified under subsection (d) of this section, and except for anti-slip floor coverings or applications that may be used for safety reasons, the floors, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 28 of 32 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 10/24/2024 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable, (Air vents must be tested for possible mold contamination and must be cleaned properly) Below is the City Ordinance Section where it states that the establishment must cease operations in the case of a sewage backup: Sec. 18-86. - Correction of violations 1. If an imminent health hazard exists, such as complete lack of refrigeration or sewage backup into the establishment, the establishment shall immediately cease food service operations. Operations shall not be resumed until authorized by the city. Record review of Retail Food Establishment Inspection Report dated 10/24/2024 from Health Department Inspector revealed, Complaint Follow-up. A follow-up inspection was performed at 12:30 PM to ensure there were no sewage backup violations. The DFSM stated there had not been any issues Health Department Inspector's last visit. Upon inspection, noticed that there were no violations to report. No Issues with the following: Air Vent Buildup Air Gap in Drains Water Backup Record review of facility's policies and procedures for Food Safety dated June 1, 2019 reflected in part .d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent covered containers. e. Use all leftovers within 72-hrs. (3-days). Discard items that are over 72 hrs. old h. Store all items at least 6 inches above the floor to protect from contamination. Record review of facility's policies and procedures for Food Safety Requirements dated 2004 reflected in part b. foods/beverages be stored in a clean, dry area off the floor to prevent cross contamination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 29 of 32 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 10/24/2024 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)

F 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for 1 of 2 dumpster reviewed for food and nutrition services. Residents Affected - Many -The facility failed to ensure the dumpster door was closed at all times when no one was dumping garbage . This failure could place residents at risk of infection from improperly disposed garbage. Findings include: Observation on 09-30-24 at 8:15 am, revealed the facility's dumpster area, which was in the lot behind the dietary department, had a commercial-size dumpster ¾ full of garbage and dumpster door was open. In an interview on 09-30-24 at 8:45 am, with the Dietary Food Service Manager, she stated that the dumpster door, when not in use, should have the doors closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. She stated housekeeping, and nursing also discarded their waste garbage in the dumpster. It was the responsibility of staff from dietary, nursing and housekeeping for ensuring the dumpster doors were kept closed when not in use. Record review of facility's Policies and Procedures on waste disposal of garbage and refuse dated 6/2019 reflected, trash containers, liners are received and collected .5. Cover waste containers and close dumpster at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 30 of 32 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 10/24/2024 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)

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, interview, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 9 (Resident #88) residents reviewed for infection control. Residents Affected - Few 1. The facility failed to ensure Resident #88's oxygen cannula that was found underneath two bedsheets and a blanket on her bed was properly disinfected before RN G placed the cannula in a plastic bag. Thisese failures could place residents at risk of cross-contamination and development of infection. Findings included: 1. Record review of Resident #88's face sheet dated 09/30/2024 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with medical diagnoses including: chronic obstructive pulmonary disease (lung condition that limits airflow in and out of the lungs due to swelling and irritation), dysphagia (difficulty swallowing), Major Depressive Disorder, Post-Traumatic Stress Disorder, hypothyroidism (underactive thyroid gland), and hypertension (high blood pressure). Record review of Resident #88's Quarterly MDS assessment dated [DATE] revealed she had a BIMS (short assessment of mental status) score of 15, indicating high cognitive intactness. Further review showed Resident #88 used a wheelchair and that she was fully independent in all self-care activities except for showering or bathing, where she required set-up or clean-up assistance. Record review of Resident #88's MAR (medication administration administration) for September 2024 revealed she had physician orders that started on 10/16/2023 for oxygen at 2-6 liters per minute to keep O2 sats above 92% as needed. Record review of Resident #88's care plan last reviewed 09/10/2024 revealed she had a focus area of shortness of breath and was at risk for respiratory distress or failure and increased episodes of SOB (shortness of breath) as evidenced by COPD diagnosis. Resident #88 refused to be sent to the ER for evaluation after complaining of SOB on 04/29/2024. Interventions included: applying o2 per order, check pulse oximetry as ordered, and observe for s/sx of respiratory infection and report any noted to MD. There were no orders for her behavior of removing oxygen cannula against physician orders. Observation of Resident #88's room on 09/30/2024 at 9:30 am, revealed the oxygen cannula was on the bed underneath two sheets and one blanket near the left edge of the bed. Interview with RN G on 09/30/2024 at 9:30 am, RN G came into the room and took the cannula out and put it in a clean bag. RN G stated a risk of keeping the cannula on the mattress would be it could catch fire and infection control. Interview with Resident #88 on 09/30/2024 at 12:55 pm, she stated that her oxygen was working well and she had no issues and stated that she measured her own oxygen because she was a smoker. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 31 of 32 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 10/24/2024 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with the Administrator on 09/30/2024 at 11:45 am, she stated that Resident #88 leaving her cannula on the bed could be an infection control issue, but in her case, the resident was care-planned for that behavior. In a later interview with the Administrator and RNC on 09/30/024 at 2:16 pm, the RNC said Resident #88 tended to lay her cannula on the sheet. The RNC said that the nurses should have cleaned the cannula when Resident #88 laid it on her bed but that it is not an infection control issue because it was unknown if Resident #88 placed the cannula back on for use without it being cleaned first. The RNC said Resident #88 had been at the facility for a few years and was independent. Record review of the facility's Infection Control Program dated February 2022, it stated, the foundations of a facility's infection control and prevention program is evidence-based policies and procedures which includes decreasing the risk of infection and communicable diseases to residents . and provide staff education A request was made to the Administrator for the facility's Oxygen policy on 09/30/2024 at 2:06 pm by email; no policies were received before exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 32 of 32