Inspection·August 23, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The surveyor asked if there were any bariatric briefs in the facility prior to the order. She stated that she could not recall if bariatric briefs before the order. The surveyor asked who is responsible for ordering briefs and how do they know what is needed. Central Supply Coordinator walk around to each unit of the facility and ask clinical staff (nurses and CNAs) what supplies are need prior to place an order for supplies. The surveyor asked if this is the only process used to inventory supplies. Central Supply Coordinator stated that this is the only inventory process used at the facility. The surveyor asked what happens if staff dose not identify an item that is needed. Central Supply Coordinator stated that the item is not ordered and will be ordered with the next order. The surveyor asked how often supplies are ordered. Central Supply Coordinator stated that supplies are ordered each week on Monday and received on Wednesday. The surveyor asked is it possible that the facility have been out of briefs for the past two weeks. Central Supply Coordinator stated that is possible as the facility do not have very many bariatric residents. The surveyor asked how many bariatric residents are there. Central Supply Coordinator stated she did not know. The surveyor asked what could happen if the wrong sized briefs are used for bariatric residents. Central Supply Coordinator stated that it could possibly cause skin irritation for the resident. During follow up interview with resident #159 and resident #160 on 08/17/2023 at 9AM, both residents stated the facility continued to provide the wrong sized briefs. During an observation of the central supply stocking area on 08/17/2023 at 9:30AM, the facility did not have a supply of bariatric briefs to accommodate bariatric resident population. The XL was largest sized stocked of briefs During follow up interview with Central Supply Coordinator on 08/17/2023 at 9:45, the surveyor asked if bariatric briefs were received via Did you ask anyone this? Did you verify they did not get a shipment on 08/16/23. Central Supply Coordinator stated that bariatric briefs not received. Central Supply Coordinator stated that the facility staff will be going to a sister facility shortly to pick up a supply of bariatric briefs. The surveyor asked if she would provide a copy of the inventory orders for the past month. Record review of product requested invoice dated 08/14/2023 indicated that bariatric briefs had not been ordered on 08/14/2023 and were not expected to be delivered on 08/16/2023. Record review of product requested invoices indicated that bariatric briefs had not been order for the month of August. During an interview on 08/17/2023 at 9:50 with Unit Manager, the surveyor asked if they were made aware facility have not had a supply of bariatric briefs for at least two weeks. The Unit Manager stated that she was not aware. The surveyor asked what could possibly happen if the wrong sized briefs are used for bariatric residents. The Unit Manager stated that it could possibly cause skin irritation for the resident. During an interview on 08/17/2023 at 10AM, with the Director of Nursing (DON), and the Regional Resource Nurse the surveyor asked if they were made aware facility have not had a supply of bariatric briefs for at least two weeks. The DON stated that she was not aware. The Regional Resource Nurse stated that she was made aware on the morning of 08/17/2023. The Regional Resource Nurse stated that the facility staff went to a sister facility this morning to pick up a supply of bariatric briefs. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675321 If continuation sheet Page 2 of 11 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 675321 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502 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 0558 Level of Harm - Minimal harm or potential for actual harm surveyor asked who is responsible for ensuring that supplies are available to accommodate resident's needs. The Regional Resource Nurse stated that all staff is response ensuring that residents are accommodate. The surveyor asked what could possibly happen if the wrong sized briefs are used for bariatric residents. The Regional Resource Nurse stated that it could possibly cause skin irritation for the resident. The surveyor requested the facility policy related to accommodation of needs. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675321 If continuation sheet Page 3 of 11 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 675321 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502 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 observations, record reviews and interviews, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection of COVID 19 for the facility and for 3 out of 5 (Resident #308, Resident #309 and Resident #311) reviewed for commincable diseases and for 1 (Resident #439) of 5 residents reviewed for infection control in that: Residents Affected - Some 1.) The facility failed to maintain Airborne Precautions for Resident #308, Resident #309 and Resident #311. 2.) The Wound Care Nurse and (CNA - K) failed to use proper hygiene technique when moving from a dirty area to a clean area while providing wound care to Resident #439. These failures could affect the facility's residents and staff, placing them at risk for communicable diseases and infection. Findings Include: 1.) During an interview on 08/16/2023 at 10AM, with the Facility Administrator (AF), Director of Nursing (DON), and the Regional Resource Nurse (who also identifies herself as the part time Infection Preventionist) the surveyor asked if there were any confirmed COVID 19 positive residents and/or staff in the facility. The DON stated that the staff member reported to work on Sunday, 08/13/ 2023 with signs and symptoms COVID 19. The DON stated that the agency contract nurse (who was later confirmed and identified as facility CNA- S) worked the start of her shift (night shift - 10am - 6am) on Sunday, 08/13/2023 after reporting to the Charge Nurse that she was not feeling well. The DON stated that the (CNA- S) was later tested and sent home on Sunday, 08/13/2023 night approximately two hours after the scheduled shift started. The DON stated that she was made aware that (CNA- S) tested positive for COVID-19 on shortly after the Charge Nurse administered a rapid COVID 19 test. The DON could not recall the specific time she was notified on 08/13/2023 night. The DON revealed the (CNA- S) worked on the 300 hall of the facility and had access to residents residing in the facility and the facility's staff working on Sunday, 08/13/2023 prior to (CNA- S) being sent home. During the interview, the surveyor inquired about actions implemented to prevent or reduce the risk of transmission. The DON stated that she had been in her role as the DON of the facility since June/2023 but disclosed that she was not familiar with the facility's policy and procedure and steps to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675321 If continuation sheet Page 4 of 11 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 675321 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502 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 take following the occurrence of a confirmed infection of COVID-19 in the facility. She stated that the (CNAS) was sent home, but no additional actions were implemented. Record review of labor allocations confirmed that (CNA- S) worked, Sunday, 08/13/2023 night 10:55PM 12:02 AM. Residents Affected - Some Record review of documentation provided by Infection Preventionist reflected two COVID - 19 Ag Tests with confirmed positive results for (CNA- S) on during shift on 08/13/2013. During interview on 08/16/2023 at 11AM with nurse responsible for the 300 Hall, (LVN - K), the surveyor asked the nurse if she was made aware of was notified of a recent positive COVID 19 occurrences within the facility. (LVN - K) stated that she was not notified of recent positive COVID 19 occurrences within the facility. During an interview at 08/16/2023 at 2:16PM, with the FA and the Infection Preventionist, the surveyor asked who is responsible for reporting confirmed positive case of COVID - 19 to HHSC CII and notifying staff. The Infection Preventionist stated that it is a team effort but did not identify who is responsible. The surveyor asked if there was a reason why the occurrence was not reported to HHSC CII. Infection Preventionist stated that she did not know why the case wasn't reported. The FA stated that she just started working at the facility on Monday, 08/14/2013 but was not aware of the COVID 19 occurrences within the facility. The surveyor asked was there a reason why the staff was not notified. Infection Preventionist stated that she was made aware on 08/16/2023. Infection Preventionist stated this is usually tracked by the Infection Preventionist and staff is usually notified. She confirmed that there was a system failure and breakdown in communication. Facility administrator, the Infection Preventionist, and DON disclosed that COVID-19 testing had not be performed on other facility staff and residents who were possibly exposed and had contact with (CNA- S). The Infection Preventionist stated that COVID 19 testing was being completed on residents on 08/16/2023 (3 days after having contact with CNA S). The surveyor attempted to contact (CNA- S) via telephone call on 08/16/2023 at 4:46PM, voicemail left requesting a follow up. The surveyor attempted to contact (CNA- S) via telephone call on 08/17/2023 at 8:30AM, voicemail left requesting a follow up. No follow up telephone call from (CNA- S) as of 08/17/2023 at 5:00PM. 2.) During an interview on 08/22/2023 at 9AM, with the Facility Administrator and the Regional Resource Nurse the Regional Resource Nurse stated that 3 of 5 sample residents residing on the 300-hall tested positive for COVID 19 on 08/19/2023. Record review of Resident #308 face sheet dated 08/23/2023 indicated she was a [AGE] year-old male who admitted on [DATE] with the immobility syndrome (paraplegic), pressure ulcer of the sacral, pressure ulcer of let hell (unstageable), bacterial infection, urinary tract infection, hematuria, chronic osteomyelitis, diarrhea, anxiety disorder, chronic pain due to trauma, constipation, colostomy, and neuromuscular dysfunction of bladder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675321 If continuation sheet Page 5 of 11 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 675321 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502 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 Record review of Resident #309 male admitted on [DATE] resident face sheet and admitting diagnosis requested three times but not provided by the facility staff prior to surveyor exit. Record review of Resident #311 male admitted on [DATE] resident face sheet and admitting diagnosis requested three times but not provided by the provided by the facility staff prior to surveyor exit. Residents Affected - Some Record review on 08/22/2022 of resident roster and facility report, Resident #308, Resident #309 and Resident #311 tested positive for Covid-19 infection at the facility on 08/19/2023, after having close contact with facility staff (CNA- S) on 08/13/2023. According to the report Resident# 308 Resident #309 and Resident #311 were to be placed on Isolation Airborne Precautions through at least day 5 (08/24/2023). Observation 1) on 08/22/2023 at 11:00AM, Resident #308, Resident #309 and Resident #311 Isolation Precaution was not being maintained. The three residents were observed in their rooms with the doors opened and not wearing facemasks. Observation 2) on 08/22/2023 at 11:41AM, Resident #309 and Resident #311 Isolation Precaution was not being maintained. Both residents were observed in their rooms with the doors opened and not wearing facemasks. During an interview on 08/22/2023 at 11:50 with (CNA - R) on the unit, the surveyor asked (CAN-R) if the three identified residents were on Isolation Airborne Precautions. (CNA-R) confirmed that Isolation Airborne Precautions should be maintained for the three residents. (CNA - R) stated the room door of Resident #309 was broken at the time of the interview. (CNA - R) further demonstrated that she was unable to close and secure the resident's room door. (CNA - R)was able to close the room door of Resident #311. The surveyor asked (CAN-R) if she had knowledge of why Isolation Airborne Precautions should be maintained for the three residents. (CNA-R) stated that the three residents were COVID 19 positive. The surveyor asked (CAN-R) if she had been educated and trained on infection control and Isolation Airborne Precautions. (CNA-R) confirmed that she had been educated and trained on infection control and Isolation Airborne Precautions. The surveyor asked (CAN-R) what was her knowledge related to a resident's room door when a resident is placed on Isolation Airborne Precautions. (CNA-R) stated that the door is to remain close. The surveyor asked (CNA--R) what could happen if the room door does not remain closed to a resident who is placed on Isolation Airborne Precautions. (CNA--R) stated that COVID 19 could spread in the facility. The surveyor asked (CNA--R) if there was reason Isolation Airborne Precautions was being maintained Isolation Airborne Precautions Resident three identified residents. (CNA-R) stated that she did not leave the residents room doors open and did not have knowledge of who left the residents room doors open. The surveyor asked (CNA--R) who is responsible for maintaining Isolation Airborne Precautions of the residents. (CNA-R) stated that everyone is responsible. The surveyor asked (CNA--R) when was she first aware of the residents' room door being broken. (CNA-R) stated the room door had been broken for a while. Surveyor asked her to clarify, (CNA-R) prior to the start of shift (6AM.). Surveyor asked room door was broken prior to today. (CNA-R) stated the room door had been broken for more than a week. The surveyor asked if administration was notified of the room door being broken. (CNA-R) stated that she did not know. The surveyor asked (CNA--R) if a maintenance order had been submitted to repair the residents' room door. (CNA-R) stated that she was not aware if a maintenance order was submitted. The surveyor asked (CNA--R) if she knew who the Infection Preventionist of the facility was. (CNA-R) stated that she did not know who the facility Infection Preventionist was. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675321 If continuation sheet Page 6 of 11 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 675321 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502 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 - Some During interview on 08/22/2023 at 12N with nurse responsible for the 300 Hall, (LVN - K), the surveyor asked the nurse if the three identified residents were on Isolation Precautions. (LVN - K), confirmed that Isolation Airborne Precautions should be maintained for the three residents. The surveyor asked (LVN - K) if she had knowledge of why Isolation Airborne Precautions should be maintained for the three residents. (LVN - K) stated that the three residents were COVID 19 positive. (LVN - K) confirmed that she had been educated and trained on infection control and Isolation Airborne Precautions. The surveyor asked (LVN - K) what could happen if the room door does not remain closed to a resident who is placed on Isolation Airborne Precautions. (LVN - K) stated that COVID 19 could spread in the facility. The surveyor asked (LVN - K) if there was reason Isolation Airborne Precautions was being maintained the three identified residents. (LVN - K) state that she was not aware that the room door was open. The surveyor asked (LVN - K) if she knew who the Infection Preventionist of the facility was. (LVN - K) stated that she did not know who the facility Infection Preventionist was. During an interview on 08/22/2023 at 12:10PM with the Infection Preventionist, the surveyor asked Infection Preventionist if Isolation Airborne Precautions should be maintained for Resident #308, Resident #309 and Resident #311. Infection Preventionist confirmed that Isolation Airborne Precautions should be maintained for the three residents. The surveyor asked Infection Preventionist who is responsible for maintaining Isolation Airborne Precautions of the resident. Infection Preventionist stated that all staff is responsible. The surveyor asked Infection Preventionist who is responsible for ensuring that intervention is implemented. Infection Preventionist stated that she and the administrative team are responsible. The Infection Preventionist did not share how often environmental rounds are completed. The surveyor asked Infection Preventionist if she aware that Resident# 308, Resident #309 and Resident #311 Isolation Airborne Precautions was not being maintained. Infection Preventionist stated that signs were placed on the residents' room doors. The surveyor asked Infection Preventionist if she was aware that Resident #309 room door is broken and dose not close. Infection Preventionist stated that she was not aware. Infection Preventionist stated that the maintenance staff was not in the build at the time of the interview, but she would work on having the room door repaired. The surveyor asked the Infection Preventionist what could happen if Isolation Airborne Precautions is not being maintained for Resident# 308, Resident #309, and Resident #311. Infection Preventionist stated other residents and staff could be exposed to COVID 19. The surveyor asked if staff has been trained in preventing the development and transmission of communicable diseases and infection. Infection Preventionist stated infection control education has been provide to all facility staff. Record review of the facility's policy, titled COVID-19 Facility Essentials Toolkit, dated 11/01/22, reflected Airborne Isolation 2.) Keep the room door closed and the resident in the room . According to record review of provided documentation, Infection Preventionist completed Nursing Home Infection Preventionist Training Course (60-minute Web -based) on 12/29/2021. The surveyor asked is there a reason why facility staff is not able to identify who the facility's Infection Preventionist is. Infection Preventionist stated that she works part time in the facility but is working to train another staff member. 3.) Record review of Resident #439 face sheet dated 08/23/2023 indicated he was a [AGE] year-old (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675321 If continuation sheet Page 7 of 11 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 675321 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502 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 - Some male who admitted on [DATE] with primary diagnosis, of sepsis, chronic obstructive pulmonary disease, hyponatremia, acute kidney failure, and cellulitis of abdominal wall. Surveyor's observation on 08/22/23 at 2:00pm, of wound care provided to Resident #439 by the Wound Nurse, who was assisted by CNA - K. Cross contamination was observed as the wound was being cleaned. The CNA - K was positioned to hold the resident's leg while the nurse provided wound care. The Wound Nurse was observed cleaning five different areas of the resident's right leg and right heel. Between cleaning each area of the resident's wounds, the Wound Nurse removed her dirty gloves and dipped her hand into a single cup of hand sanitizer, applied new gloves, cleaned a different area of the wounds, removed her dirty gloves, and utilized the sanitizer by dipped her hand into the same single cup of hand sanitizer. The Wound Nurse continued wound care and repeated the same steps of removing gloves and utilized the sanitizer by dipping her hands in the same cup of hand sanitizer five times. The CNA - K was observed holding the resident's leg and heel during wound care. After the Wound Nurse cleaned the resident's wound, the CNA K did not change her dirty gloves to apply clean gloves while wound care was provided. The same gloves used to touch the dirty area of the wound was used to touch the cleaned area of the wound on the right leg and heel. The Wound Nurse applied clean wound dress to the contaminated wound area. During an interview with the Wound Nurse, the surveyor asked the Wound Nurse has she been educated and training as a wound care nurse. Wound Nurse stated that she has been and in competent ibn providing wound care. The surveyor asked the Wound Nurse about her technique during the wound care. The Wound Nurse stated that she was utilizing the same technique she's always used while providing wound care. The surveyor asked her if she sanitized her hands properly. The Wound Nurse stated that she did not sanitize her hands properly but stated that she was told a while back that she it was okay to dip her hand into a cup of contaminated sanitizer. She confirmed that the technique used to sanitize her hands was a form of cross contamination after the first use of dipping her hand into the sanitize. The surveyor asked her if she had education on infection control. The Wound Nurse stated that she had been educated. The surveyor asked her what could happen to a resident when infection control interventions were not implemented. Wound Nurse stated that the resident could develop an infection and wound healing can be delayed. The surveyor asked the Wound Nurse if she was aware that the reference resident (Resident #439) have experienced delayed wound healing of the right heel (the same wound that being care for during the surveyor's observation). The Wound Nurse stated that she was aware that the wound had not changed much. The surveyor asked if the delayed healing could be a result of infection control interventions were not implemented. Wound Nurse stated that it is possible. During interview with CNA - K , acknowledged that she had education on infection control. The surveyor asked her if there was a reason, she did not change her gloves. The CNA - K stated that she forgot to change her gloves during the transition from the dirty to the cleaned wound. The surveyor asked her if she recall touching the wound on right heel and leg after the wound had been cleaned by the nurse. The CNA K confirmed that she did touch the wound with her dirty gloved hands after it was cleaned. The surveyor asked what could happen to a resident when infection control interventions were not implemented. CNA - K stated that the resident could get an infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675321 If continuation sheet Page 8 of 11 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 675321 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502 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 - Some The surveyor asked Wound Nurse and (CNA - K) if they knew who the Infection Preventionist of the facility was both stated that they did not know who the facility Infection Preventionist was. During an interview on 08/22/2023 at 12:10PM, the surveyor asked if staff has been trained in preventing the development and transmission of communicable diseases and infection. Infection Preventionist stated infection control education has been provide to all facility staff. Record review of wound care documentation provided by the Wound Nurse indicates that there has been a delay in the healing of Resident #439 right heel wound. Within a three-month period, wound care documentation reflects the wound is not improving. While there is no medical indication supporting the delay in the healing. This deficient practice could have delayed wound healing for Resident #439. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675321 If continuation sheet Page 9 of 11 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 675321 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502 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 0885 Report COVID19 data to residents and families. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of a confirmed infection of COVID-19 for one staff member in the facility. Residents Affected - Some The facility failed to inform residents that a facility staff member (CNA- S) tested positive for COVID-19 on 08/13/2023. This failure placed residents, families, and responsible parties at risk related to not being kept informed on the Covid-19 status in the facility. Findings included: During an interview on 08/16/2023 at 10AM, with the Facility Administrator (AF), Director of Nursing (DON), and the Regional Resource Nurse (RRN) the surveyor asked if there were any confirmed COVID 19 positive residents and/or staff in the facility. The DON stated that the staff member reported to work on Sunday, 08/13/ 2023 with signs and symptoms COVID 19. The DON stated that the agency contract nurse (who was later confirmed and identified as facility CNA- S) worked the start of her shift on Sunday, 08/13/2023 (night shift - 10am - 6am) after reporting to the Charge Nurse that she was not feeling well. The DON stated that the (CNA- S) was later tested and sent home on Sunday, 08/13/2023 night approximately two hours after the scheduled shift started. The DON stated that she was made aware that (CNA- S) tested positive for COVID-19 on shortly after the Charge Nurse administered a rapid COVID 19 test. The DON could not recall the specific time she was notified on 08/13/2023 night. At the time of the interview the DON stated that the facility did not notify residents and the families of the confirmed infection of COVID-19 because she was not aware of the facility's policy and did not know that residents and their families had to be notified. During an interview the surveyor asked the FA and the RRN (who also identifies herself as the part time Infection Preventionist) what is the facility's process for notifying residents and family members of positive COVID 19 occurrences within the facility. Infection Preventionist stated the facility should notify the residents and family's as within 24 hours. The surveyor asked who is responsible for notifying the residents and families. She stated that it is a team effort but did not identify who is responsible. The surveyor asked if there was a reason that the families were not notified. She stated that she did not know why the families weren't notified. The surveyor asked who is held accountable if residents and families are not notified. Infection Preventionist stated this is usually tracked by the Infection Preventionist. She confirmed that there was a system failure and breakdown in communication. During interview on 08/16/2023 at 11:10AM with Resident#316, the surveyor asked the resident if she was familiar with (CNA- S). The resident confirmed that he was familiar with (CNA- S). The surveyor asked the resident if he recalled when (CNA- S) last assisted her. The resident confirmed that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675321 If continuation sheet Page 10 of 11 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 675321 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Faith Memorial 811 Garner Rd Pasadena, TX 77502 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 0885 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (CNA- S) worked with her over the weekend, including Sunday, 08/14/2023. The surveyor asked the resident if she was notified of a recent positive COVID 19 occurrences within the facility. The resident stated that she was not notified of recent positive COVID 19 occurrences within the facility. During interview on 08/16/2023 at 11:00AM with Resident#308, the surveyor asked the resident if he was familiar with (CNA- S). The resident confirmed that he was familiar with (CNA- S). The surveyor asked the resident if he recalled when (CNA- S) last assisted him. The resident confirmed that (CNA- S) worked with him on Sunday, 08/14/2023 night. The surveyor asked the resident if he was notified of a recent positive COVID 19 occurrences within the facility. The resident stated that he was not notified of recent positive COVID 19 occurrences within the facility. Record review of the facility's policy, titled COVID-19 Facility Essentials Toolkit, dated 11/01/22, reflected Notify HCP, residents, and family promptly about COVID - 19 in the facility . The surveyor attempted to contact (CNA- S) via telephone call on 08/16/2023 at 4:46PM, voicemail left requesting a follow up. The surveyor attempted to contact (CNA- S) via telephone call on 08/17/2023 at 8:30AM, voicemail left requesting a follow up. No follow up telephone call from (CNA- S) as of 08/17/2023 at 5:00PM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675321 If continuation sheet Page 11 of 11