Inspection·June 1, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few gloves, positioned Resident #1 to receive eye drops then removed the medication cap of the Latanoprost eye drops and placed the cap inside facing down on top the nightstand. The nightstand was not disinfected prior to the procedure. MA- A instructed Resident #1 to open her eyes wide. Resident #1 slightly opened her eyes. MA- A held the bottle over Resident #1's right eye and instilled one drop. MA-A instructed Resident #1 to close her eyes. Resident #1 had her eyes closed for three seconds. MA-A instructed Resident #1 to open her eyes and attempted to instill a drop into the left eye, resident blinked, and the solution did not enter into the eye. MA-A attempted again, and 2 drops entered the eye. Resident #1 closed both eyes, MA-A wiped excess solution using a clean tissue. MA-A replaced the medication cap onto the bottle, removed gloves and sanitized hands. In an interview on 06/01/25 at 6:53 PM, MA-A stated Resident #1's eye drop order was one drop per eye. MA-A stated Resident #1 was receiving Latanoprost eye drops because she does not see clearly. MA-A stated she was taught to drop medication into the inside of the eye by the medication aides who had been working at the facility for a long time. MA-A stated she received training during orientation in February 2025. MA-A stated normally she would put the medication cap in a way it would stay clean, but she was nervous. In an interview on 6/01/25 at 7:12 PM, LVN-B stated when administering eye drops she would wash hands, put on clean gloves, pull lower eye lid down, administer eye drop into the lower portion of the eye then have the resident close their eye and massage the lower lid or ask the resident to close eyes and move eye ball around in order to better absorb and spread the medication. LVN-B stated Resident #1 needs the Lantanoprost eye medication for glaucoma and if not instilled correctly her vision could worsen. LVN-B stated she would ensure the tip of the dropper stays clean by putting the medication cap on a clean surface upside down on a clean surface so the inside of the cap remains clean otherwise if the cap is placed facing down it could contaminate the tip of the dropper when the cap is replaced, and this could possibly cause an eye infection. LVN-B stated she will follow up and re-educate MA-A and notify the DON so a new bottle can get ordered and the old bottle should not be used again. In an interview on 6/1/25 at 8:20 PM the DON stated she expected nurses and medication aides to put on clean gloves, pull down on the lower eye lid and instill the ordered number of eye drops into the lower lid area. Then have the resident close their eyes. The DON stated if the facility policy and procedure was not followed the resident may not receive the full dose. The DON stated Resident #1 receives Latanoprost for glaucoma or cataracts. The DON stated it was important to ensure the tip of eye dropper stays clean to reduce chance of infection. The DON states she would hold the medication cap in the palm of her hand and would not put the cap down on a surface as it could potentially cross-contaminate the tip of the dropper and cause eye infection. The DON stated she would conduct in-service with MA-A on proper administration of eye drops. Record review of MA-A's Medication Aide-Medication pass competency check list dated 2/30/25, indicated the performance criteria was met for eye drop administration including to gently pull down the lower eyelid to form a pouch while instructing the resident to look up. Further review indicated MA-A signed the checklist and was evaluated by the Lead MA. Record review of the facility policy and procedure for Medication Administration and Management revised on June 2019, read in part: It is the policy of this facility that the facility will implement an Medication management Program that incorporates systems with established goals to meet each resident's needs as well as regulatory requirements .9. The authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff member administers eye medications as follows: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455812 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete A. Administer according to pharmacy/manufacturer specifications .G. Use the index finger to pull down the lower lid. H. Instruct the resident to look up. I. Steady your hand holding the dispenser against the resident's forehead, and instill the drop inside the lower lid L. Release the eyelid, instruct resident to close eyes slowly, and gently wipe off excess medication with a clean tissue from the inside to the outside .O. If indicated, it may be necessary to apply pressure to the tear duct (inner canthus) following the instillation of a specific eye drop for one (1) minute or per manufacturer's specifications . Event ID: Facility ID: 455812 If continuation sheet Page 3 of 3