Health inspection·December 4, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #1 and Resident #20) of 14 residents reviewed for call lights. Staff failed to ensure Resident #1 and Resident #20's call bells were within reach. This failure could place residents at risk for decreased self-worth, quality of life, and dignity.Findings included:1. Review of Resident #1's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses in part including dementia, restlessness and agitation, unspecified lack of coordination, weakness, and a history of traumatic brain injury (brain injury caused by outside force). Review of Resident #1's Comprehensive Care Plan revised 11/28/25 reflected Resident #1 had a history of falling. An intervention with start date 3/04/24 stated, keep call light in reach at all times.Review of Resident #1's MDS assessment dated [DATE] reflected that the resident was severely cognitively impaired. Resident #1 required partial/moderate assistance with mobility and at least substantial assistance with self-care activities.2. Review of Resident #20's face sheet dated 12/02/25 reflected a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses in part of pneumonitis (inflammation of the lungs), weakness, and paraplegia (paralysis affecting the legs). Review of Resident #20's Comprehensive Care Plan revised 10/07/25 reflected Resident #20 had a history of falling. An intervention with start date 3/24/25 stated, keep call light in reach at all times. Review of Resident #20's MDS assessment dated [DATE] reflected that the resident was moderately cognitively impaired. Resident #20 was dependent on assistance with mobility and required at least partial/moderate assistance with self-care activities. In an observation and interview on 12/02/2025 at 9:04 a.m., Resident #1 was noted laying sideways in his bed and his call bell was observed curled up and hung on the wall past the foot of the bed and out of the reach of the resident. A fall mat was observed beside the bed. Resident #1 stated his brief was wet, and he needed assistance. Resident #1 did not answer when asked further questions about his call bell. Staff were informed of Resident #1's request, and CNA A came promptly to assist the resident. In an observation on 12/02/25 at10:56 a.m., Resident #20 was observed in bed. His call bell cord was wrapped around the siderail of the bed with the push-pad hanging down from the bed approximately 2 feet and out of reach of Resident #20. In a follow-up observation and interview on 12/03/25 at 11:57 a.m., Resident #20 was observed in bed, and his call bell remained out of reach in the same location as seen on 12/02/25 at 10:56 a.m Resident #20 stated that he wanted more water to drink but that his call bell was on the floor somewhere. He expressed frustration with being unable to call for assistance and stated, there is a law about that. He did not know how long his call bell had been out of reach. He stated his call bell was typically within reach. Resident #20 stated he could not walk or otherwise obtain assistance without using his push-pad call bell. In an observation on 12/02/25 at 12:02 p.m., CNA A walked into the room and Resident #20 told him he wanted his drink refilled. Resident #20's call bell Residents Affected - Few Page 1 of 6 455831 455831 12/04/2025 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was not within his reach. CNA A took the cup and left the room without changing the placement of the call bell. CNA A returned shortly with the drink and began preparing the resident for incontinence care and transfer.In an interview on 12/02/25 at 12:08 p.m., CNA A stated that he had observed Resident #1s call bell hanging on the wall this morning (12/02/25) when he was asked to assist him with incontinence care around 9 a.m He stated the call bell should have been within the resident's reach and that, I am guessing someone may have hung it up when changing his bed and forgot to give it back to him. He stated staff check for the placement of the call bell before leaving a residents' room, and he had placed the call bell back within reach of Resident #1 when he finished providing care. CNA A stated that Resident #20's call bell, which was found hanging down from the bed, was supposed to be on the bed but if he moved his pillow or something, it might have fallen off. He stated the risk of a resident not having their call light was, we would just have to check on them periodically because it will slide off at times. In an interview on 12/02/2025 at 12:10 p.m., CNA B stated that Resident #20's call bell was hanging down from his bed and not within his reach when she came into the room today (12/02/25) at approximately 12:05 p.m. to assist CNA A with providing care. She stated that staff monitored the placement of residents' call bells continuously. She stated that without his call light being in reach Resident #20 was at risk for, not being able to call for help and us not knowing if he needed anything.In an interview on 12/02/2025 at 1:40 p.m., RN C stated she was Resident #1s nurse today (12/02/25) and she was not aware that he was without his call bell being within reach at any time today. She reported that all staff monitored the call bell placement with every patient interaction. She reported that Resident #20's call bell should always be within his reach and that without it he would be at risk of not being able to get assistance.In an interview on 12/02/2025 at 2:04 p.m., the ADM stated that, the standard is for the call bell to be within reach and that a resident without their call bell within reach was at risk for, his needs may not be met immediately. She stated the expectation was that all staff would monitor the placement of call bells. She reported she would be implementing immediate staff training on the need for residents' call bells to be within reach.In an interview on 12/03/2025 at 2:12 p.m., the ADON stated that all staff had received training upon hire on the need for residents' call bells to be within reach. She reported it is the expectation that the call bell be placed within the reach of the resident. She stated the risk of a resident not being able to reach their call light was, a lot of things can happen and they can't get their needs met.Review of the facility policy titled Call System, Residents, with revision date September 2022, revealed, Each resident is provided with a means to call staff directly for assistance from his/her bed . 455831 Page 2 of 6 455831 12/04/2025 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident received an accurate assessment, which was reflective of the resident's status for one (Residents #27) of four residents reviewed for accuracy of assessments. The facility failed to ensure Resident #27's (a discharged resident) most recent quarterly and discharge assessments accurately reflected his physical behaviors directed at others. This failure could place residents at risk of not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health.Findings included: Review of Resident #27's Face Sheet, dated 12/02/25, reflected a male, admitted on [DATE], and having diagnoses of congestive heart failure (a condition in which the heart cannot pump enough blood, causing fluid to build up in the body), stroke (a blood clot in the brain, causing brain damage), schizoaffective disorder (a condition with symptoms of hallucinations/delusions combined with mood problems), depression, dementia with agitation, and adjustment disorder (emotional and behavioral problems in response to stress) with anxiety and depression. A family member was listed as his responsible party. Review of Resident #27's quarterly MDS, dated [DATE], reflected the staff assessment of his mental status indicated he had a memory problem, and moderately impaired daily decision-making skills, no delirium, and no physical, verbal, or other behavioral symptoms, as well as no rejection of care in the seven-day look-back period. The document reflected Resident #27 required substantial/maximal assistance (helper does more than half the effort) for most of discharge MDS, dated [DATE], reflected he was discharged to an acute care hospital. The staff assessment of his mental status indicated he had a memory problem, and moderately impaired daily decision-making skills, no delirium, and no physical, verbal, or other behavioral symptoms, as well as no rejection of care in the seven-day look-back period. The document reflected Resident #27 required substantial/maximal assistance (helper does more than half the effort) for most of his ADLs. The document was electronically signed by the MDS Coordinator. Review of Resident #27's discharge MDS, dated [DATE], reflected he was discharged to an acute care hospital. The staff assessment of his mental status indicated he had a memory problem, and moderately impaired daily decision-making skills, no delirium, and no physical, verbal, or other behavioral symptoms, as well as no rejection of care in the seven-day look-back period. The document reflected Resident #27 was dependent on staff for toileting hygiene, putting on footwear, hygiene, refused lower body dressing, and was not bathed/showered due to his condition. The document was someone who is not there. Dated 04/22/25, revised 09/02/25 by the MDS Coordinator- Memory recall problem due to stroke. Dated 01/22/24, revised 09/02/25 by the MDS Coordinator- Potential to exhibit physically and verbally abusive behavior, with examples of hitting, shoving, scratching, and making sexually inappropriate comments toward staff. A note that Resident #27 struck another resident was made on 09/02/24. Dated 08/14/23, and revised 09/02/25 by the MDS Coordinator.- Socially inappropriate and disruptive behavior, including speaking very loudly, frequent inappropriate comments in others, and can become aggressive at times. Dated 07/03/23, and revised 09/02/25 by the MDS Coordinator.- Refusing to take medications almost daily, and refusing labs. Dated 12/22/22, and revised on 09/02/25 by the MDS Coordinator. Review of Resident #27's progress notes reflected the following:- 08/09/2025 at 9:10 AM by LVN D Made x2 attempts to give medication and assess resident this AM. Residentattempted to punch nurse in the face when trying to check radial pulse. Resident was also verbally aggressive with nurse. (.)08/09/2025 at 1:10 PM by Residents Affected - Few 455831 Page 3 of 6 455831 12/04/2025 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few LVN D When nurse entered room to check on resident. Resident asked for ice water.When nurse attempted to hand resident ice water he clawed her arm. Spoke with (Resident #27's responsible party) regarding med refusals and aggressive behaviors this shift.- 08/09/2025 at 2:55 PM by LVN D Entered resident's room to provide peri-care as resident had a BM. Resident assisted in turning over and was allowing staff to clean him. While cleansing resident he started swung fist hitting this nurse in the jaw. Resident then refused to allow staff to finishing cleaning him or placing a new brief. Provider, (Resident #27's responsible party), NP, DON, and admin notified of behavior. NP suggest referring resident to psych facility.- 08/09/2025 at 4:58 PM by LVN D (Name of portable diagnostic company) came to do EKG . Resident initially attempted to hit tech with open hand but tech was able to move out of the way. Resident did end up allowing tech to place stickers and wires. However resident would not stay still during test. Resident continues to refuse pericare. Spoke (Resident #27's responsible party) regarding continued behaviors and NPs recommendation to refer to psych facility. (Responsible party) was agreeable with recommendation.- 08/09/2025 at 7:00 PM by LVN E Noted (Resident #27's responsible party) came in the facility and checked in with the resident's behavioral status. (.) Noted continues with constant verbal and physical redirection r/t occasionally swatted staff during assisting his shower. (.)- 08/10/2025 at 9:23 AM by LVN D Resident refused meds this AM. NP aware. (Responsible party) aware of continued refusals. Resident is calm until staff enters room and then becomes verbally aggressive. Resident does not respond to redirection or education regarding behaviors or medications. Attempts to educate resident on importance of medication compliance due to cardiac history is unsuccessful. Resident states that he has a nursing and doctor degree and does not need any medicine. Resident just states, I have good pressure. Nothing is wrong with my heart. (.)- 08/10/2025 at 8:31 PM by LVN E (.)Noted continues with redirections verbally r/t occasional increased in verbalaggression towards staff. (.)- 08/15/2025 at 8:47 AM by RN F Resident continues with AM med refusals. 2 attempts made by nurse and with2nd attempt resident raises fisted arm toward nurse. (.)- 08/27/2025 at 9:38 PM by LVN E (.) called (Resident #27's responsible party), RP for resident and discussedresident's behavior and new orders. (.) Noted x 3 staff assisted with HS care, and tolerated and resident attempted to swat on one of the staff CNAs. Noted verbally redirected and tolerated. (.)- 09/02/2025 at 9:00 PM by LVN E Noted resident with multiple attempts along with staff assistance was able toassist him in his low bed, HOB elevated at around 7pm. Noted resident continues with combative behavior and attempted multiple times to physicallyredirect [sic] his behavior, and responsive most times. (.)Noted per NP telephone order to transfer resident to ER. (.) An interview on 12/03/25 at 2:09 PM with the ADON revealed Resident #27 was often agitated and the staff never knew when it was coming. She gave the example of one time when she went into his room on her room rounds, and told him she was going to check in his refrigerator. She said he seemed fine, but when she was leaving the room, a can of soda was flying at her head. She said it missed her, but it scared her. She said it was typical of Resident #27 to seem fine with what was going on, then kick or punch someone with no warning. The ADON said if he verbalized no, staff knew to get away from him immediately. An interview on 12/04/25 at 9:04 AM with LVN G revealed she had been hit by Resident #27. She said he had hit other staff, so all of the staff were aware he could do that, but she let her guard down for a moment, and he hit her hard in the jaw. An interview on 12/04/25 at 11:22 AM with CNA A revealed Resident #27 hit all the time. He said the resident would punch anyone who went into his room, unless they really understood how to talk to him. He said he usually was able to gain cooperation with Resident #27 by talking to him about the work the resident used to do, but he had punched him before. An interview on 12/04/25 at 11:36 AM with LVN D revealed Resident #27 was pretty aggressive, would rarely take 455831 Page 4 of 6 455831 12/04/2025 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few his medications, and was frequently combative. She said he would have waves when his combativeness was daily, then he might be that way a couple of times a week. An interview on 12/04/25 at 12:30 PM with RN I revealed she had worked with Resident #27 as a night nurse, and he was usually in bed and would sometimes ask her for a pain reliever, and would cooperate with her when she gave it to him, because he had asked her for it. She said she had heard some pretty horrible stories about him though. She said that she was aware of him punching a nurse in the face, and frequently hitting or kicking staff, and that she heard that he once had picked up a pill crusher and hit a staff member in the head with it, causing her to need sutures. She said that he used to kick staff with boots, but his family member came and took them away from him, and he only wore soft shoes after that. An interview on 12/04/25 at 12:48 PM with CNA J revealed Resident #27 was flirtatious with her, and did not give her many problems, but she was aware he could get violent at any time. She said he would refuse care sometimes, and she would just leave him alone until he was ready. She said she often got called to help with him, because he was combative with other staff. A telephone interview on 12/04/25 at 2:14 PM with the MDS Coordinator revealed she did not document the behaviors in the MDS because in the RAI manual it said if the behavior was already existent, and careplanned, it was not to be recorded in the MDS. During a telephone interview on 12/04/25 at 2:33 PM with the MDS Coordinator she confirmed that she had believed that the rule about not documenting behaviors in the MDS was for both the section regarding refusal of care, and the section about behaviors affecting the resident or others. She said the accuracy of the MDS was important because it was a direct reflection of the care the resident received, and inaccuracies could potentially affect the accuracy of the care plans, as well. An interview on 12/04/25 at 2:38 PM with the Regional MDS Coordinator revealed she needed to check the RAI manual, but she thought that behaviors should be recorded in the MDS, and the section regarding refusals was the only part where they would not be recorded if they were already recorded. She said the section regarding behaviors affecting the resident or others were, in part, recorded by observation, so if a resident was observed having a behavior during the lookback period, it would be recorded in the MDS, regardless of whether it was an already-known behavior. After a few minutes she returned to confirm that it was only the rejection of care section that if it was care-planned it did not have to be coded in the MDS. She said the accurate assessments were important for patient care, reimbursement and care planning. Review of the facility Resident Assessments policy, revised in March of 2022, reflected: 8. All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. Review of the current Centers for Medicare and Medicaid Services Long-Term Care Resident Assessment Instrument 3.0 User's Manual Version 1.20.1, October 2025, reflected: Section E: Behavior: Intent: The items in this section identify behavioral symptoms in the last seven days that may cause distress to the resident, or may be distressing or disruptive to facility residents, staff members or the care environment. These behaviors may place the resident at risk for injury, isolation, and inactivity and may also indicate unrecognized needs, preferences or illness. Behaviors include those that are potentially harmful to the resident themself. The emphasis is identifying behaviors, which does not necessarily imply a medical diagnosis. Identification of the frequency and the impact of behavioral symptoms on the resident and on others is critical to distinguish behaviors that constitute problems from those that are not problematic. Once the frequency and impact of behavioral symptoms are accurately determined, follow-up evaluation and care plan interventions can be developed to improve the symptoms or reduce their impact. This section focuses on the resident's actions, not the intent of their behavior. Because of their interactions with residents, staff may have become used to the behavior and may underreport or 455831 Page 5 of 6 455831 12/04/2025 Paris Healthcare Center 610 Deshong Dr Paris, TX 75460

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few minimize the resident's behavior by presuming intent (e.g., Resident A doesn't really mean to hurt anyone. They're just frightened.). Resident intent should not be taken into account when coding for items in this section. (.) E0200: Behavioral Symptom-Presence & Frequency: Subsequent assessments and documentation can be compared to baseline to identify changes in the resident's behavior, including response to interventions.Steps for Assessment 1. Review the medical record for the 7-day look-back period. 2. Interview staff, across all shifts and disciplines, as well as others who had close interactions with the resident during the 7-day look-back period, including family or friends who visit frequently or have frequent contact with the resident. 3. Observe the resident in a variety of situations during the 7-day look-back period. Coding Instructions Code 0, behavior not exhibited: if the behavioral symptoms were not present in the last 7 days. Use this code if the symptom has never been exhibited or if it previously has been exhibited but has been absent in the last 7 days. Code 1, behavior of this type occurred 1-3 days: if the behavior was exhibited 1-3 days of the last 7 days, regardless of the number or severity of episodes that occur on any one of those days. Code 2, behavior of this type occurred 4-6 days, but less than daily: if the behavior was exhibited 4-6 of the last 7 days, regardless of the number or severity of episodes that occur on any of those days. Code 3, behavior if this type occurred daily: if the behavior was exhibited daily, regardless of the number or severity of episodes that occur on any of those days. Coding Tips and Special Populations Code based on whether the symptoms occurred and not based on an interpretation of the behavior's meaning, cause or the assessor's judgment that the behavior can be explained or should be tolerated. Code as present, even if staff have become used to the behavior or view it as typical or tolerable. Behaviors in these categories should be coded as present or not present, whether or not they might represent a rejection of care. Review of the instructions within the MDS form (Resident #27's Quarterly MDS, referenced in record review above) reflected: Section E0200 Behavior Symptom Presence and Frequency: Note presence of symptoms and their frequency. (.) A. Physical behavioral symptoms directed toward others (e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually) B. Verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others) C. Other behavioral symptoms not directed toward others (e.g. physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) E0800: Rejection of carePresence and Frequency: Did the resident reject evaluation or care (e.g. bloodwork, taking medications, ADL assistance) that is necessary to achieve the resident's goals for health and well-being? Do not include behaviors that have already been addressed (e.g by discussion or care planning with the resident or family), and determined to be consistent with resident values, preferences, or goals. 455831 Page 6 of 6