Inspection·February 2, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 resident centered care plan that included measurable objectives and timeframes to meet resident's needs for 1 of 16 residents reviewed for care plan accuracy (Resident #43). --Resident # 43 did not have an individualized care plan for ADL's. This failure placed residents at risk of not receiving care according to their needs and diminished quality of life. Findings include: Record review of the face sheet for Resident # 43 revealed a [AGE] year-old female with admission date of 1/5/23. Her diagnoses included Malignant neoplasm (an abnormal number of damaged cells that grow) of part of lung, heart disease, COPD (chronic obstructive pulmonary disease causing airflow blockage), Osteoarthritis (degeneration of joint), anxiety disorder (feelings of worry, anxiety or fear that interfere with daily activities), age-related physical debility (weakness), and dementia (an organic disease of the brain that causes progressive loss of intellectual functioning with memory impairment and abstract thinking). Observation and interview on 1/31/23 at 9:45 am revealed Resident #43 in bed, alert, oriented, watching TV, with feeding tube in use and oxygen tank at bedside. In an interview at that time, she said she felt weak, so she needed help to get up out of bed, for dressing and bathing. She said she does get help when she needs it. Record review of Resident #43's Significant Change MDS dated [DATE] revealed a BIMS score of 15 (no cognitive impairment), always incontinent, and extensive physical assistance required from 1-person for transfer, dressing, eating, toileting and hygiene, and total dependence with 1-person physical assistance for bathing. Record review of the care plan initiated 1/16/23 revealed Resident #43 was unable to complete the ADL without assistance. Interventions included Resident # 43 required extensive/total assist with all ADL's. The care plan did not specify which ADL's required extensive or total assistance. In an interview on 2/1/23 at 2:15 pm, MDS Nurse said she does the care plans, with input from the IDT team. She said they talk about the residents and any changes in their conditions in their morning meetings, and she updates the care plans if needed accordingly. MDS nurse further said the care plan for Resident #43 should be more specific to show which ADL needed extensive or total assistance from staff. In an interview on 2/2/23 at 9:55 am, the DON said she expects the care plans for each resident to accurately reflect the resident's current needs and condition. She said the MDS Nurse was responsible for creating the care plans after input from the IDT team, and the ADL care plan for Resident #43 needed to be more individualized for her needs. Record review of facility policy Careplan Revisions, revised 5/22, revealed, in part: comprehensive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675344 If continuation sheet Page 2 of 5 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 675344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Sweeny 109 N McKinney Sweeny, TX 77480 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 care plan will be reviewed and revised every quarter, when a resident experiences a status change and as deemed necessary .care plan will be modified with new or modified interventions .care plans will be modified as needed by the MDS coordinator or other designated staff member . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675344 If continuation sheet Page 3 of 5 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 675344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Sweeny 109 N McKinney Sweeny, TX 77480 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 0760 Ensure that residents are free from significant medication errors. 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 did not ensure residents were free from any significant medication errors for 1 of 25 (Resident #21) residents reviewed for significant medication errors. Residents Affected - Few The facility failed to hold Resident #21's Lisinopril medication, which lowers BP, when the resident had a BP below the safe parameters for administration. This failure could place residents with BP parameters at risk for symptoms of hypotension (low blood pressure), which could include dizziness, light headedness, lethargy (abnormal drowsiness), and unresponsiveness. Findings included: Record review of Resident #21's face sheet, dated 2/2/23, indicated she was [AGE] years old, and admitted on [DATE]. Her diagnoses included Type II Diabetes (insufficient production of insulin, causing high blood sugar), Major Depression (mental condition with persistently depressed mood and long-term loss of pleasure or interest in life), Anxiety (feeling nervous, restless or tense), Heart Failure (heart doesn't pump as well as it should), and Congestive Heart Failure (when fluid backs up in the lungs because the heart is too weak to pump). Observation on 2/1/23 at 0940am revealed LVN A checked Resident #21's BP on her left wrist. Surveyor observed the BP monitor, and it was 109/66 with a heart rate of 85. LVN A proceeded to pop out all the resident's medications into the medicine cup. Surveyor and LVN both confirmed 7.5 pills in cup, and 1 lidocaine patch. LVN A proceeded into room where Resident #21 was observed sitting on the edge of the bed. Resident took all the medication with about 6oz. of water. Record review of Resident #21's physician orders revealed a medication order dated 8/2/22 for Lisinopril 10mg, 2 PO in the morning for HTN hold if SBP is less than 120. To clarify, the medication should be given unless the top number in the blood pressure reading was less than 120. Record review of Resident #21's MAR on 2/1/23 revealed administration of Lisinopril 10mg 2 PO at 0900am, even though the BP documented was 109/66, and under the medication on the MAR there was a comment that stated to hold if SBP was less than 120. The initials of the person giving the medication for the 0900 dose was that of LVN A. In an interview with LVN A on 2/1/23 at 11:44am LVN A stated she only looks at the MAR and not at the physician's orders. LVN A opened the MAR for Resident #21 and looked at the orders for Lisinopril, but stated she did not see any parameters for the BP. However, after about 10 seconds LVN A found the parameters. LVN A stated she overlooked the parameters, and she should not have given the BP medication. LVN A went and rechecked Resident #21's BP at that moment and surveyor went with her. Surveyor looked at BP monitor and it stated 147/69. Resident was observed in dining room and stated she had just finished eating, Resident #21 stated she felt fine and wasn't experiencing any symptoms. LVN A stated giving a BP medication to a resident that already had low BP could cause dizziness, and light headedness, among other symptoms. In an interview with the DON and the Administrator, on 2/1/23 at 2:30pm, the DON stated the medication should have been held due to the parameters, and LVN A should have seen the parameters and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675344 If continuation sheet Page 4 of 5 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 675344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Sweeny 109 N McKinney Sweeny, TX 77480 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete should have known to hold the medication. DON confirmed lethargy, unresponsiveness, and hypotension can occur from giving BP medication when not necessary. Record review of the facility's Medication Administration and Management policies and procedures, dated 6/2019 stated, The facility's nursing and pharmacy services will assess, monitor and evaluate the effectiveness of the therapeutic medication regimen including all the drugs (prescription and non-prescription) in order to enhance the resident's quality of life. It also stated, staff must understand indication/reasons for therapy, effectiveness of therapeutic goal, drug actions, the 8 Rights for administering medication. The authorized .medication aide .follows the MAR prepared for the patient/resident by identifying the 8 Rights .identifies that the following information, but not limited to, is documented in the MAR: Correct physician's order, Medication and label are correct, Label and physician's order are correct .reads the label on the medication (3) times. Event ID: Facility ID: 675344 If continuation sheet Page 5 of 5