Health inspection·April 20, 2023

F 0689 Level of Harm - Actual harm areas are free of clutter, ensure call light is within reach and answer promptly and keep frequently used items at resident beside. [Resident #1] is at risk for falls related to poor balance, Poor communication/comprehension, Unsteady gait. Interventions .For no apparent acute injury, determine and address causative factors of the fall. Residents Affected - Few Record review of Resident #1's Local Hospital Records, dated 4/20/23, revealed: Associated Diagnosis: Acute dehydration; Acute UTI; Altered mental status: Lethargy .Patients physician(s) chief complaint from Nursing Triage Note: Chief Complaint. 4/18/23 1:03 p.m. chief complaint lethargic, AMS stated per EMS report came via EMS due to fall from a wheelchair at [Nursing facility]. Sustain contusion to left eyebrow and face with skin tear to left hand patient appears sedated almost stoned, however it is no longer pale and her color has returned. Record review of Resident #1's SBAR (Change of Condition), dated 4/17/23 at 1:51 p.m., revealed, Witnessed fall, Assessment- What do you think is going on with the resident? Confused, RecommendationMonitor vital signs and transfer to hospital. Physician notified and POA, ER Contact or Responsible Party notified on 4/17/23 at 1:30 p.m. Record review of Resident #1's Progress note, dated 4/17/23 at 2:11 p.m., written by Charge Nurse A revealed, Resident transported to [Local Hospital]. Record review of Resident #1's Progress Notes, Physician Order Note, dated 4/17/23 at 2:13 p.m., written by [Physician], revealed Seen for routine visit. She had fall and is being seen. She has skin tears related to hand and contusion face .General: crying sitting in wheelchair face contusion on forehead above right eye right hand multiple skin tears on knuckles 2, 3 and 4. Right arm skin tear 4.0 cm . 1 fall with contusion head and focal skin tears on right hand- send to ER. Record review of Resident #1's Progress Notes, dated 4/18/23 at 1:39 p.m., written by ADON, revealed Resident attempting to get out of wheelchair. Staff went over to assist resident and as resident grabbed the handlebar on the wall, she slipped and fell from her chair. Resident hit left side of her face on the floor and also received a skin tear to her left hand . In an interview on 4/20/23 at 12:35 p.m. with Restorative Aide A she stated she did witnessed the fall of Resident #1 on the Memory Care Unit (She could not recall the date). Restorative Aide A stated CNA A went to turn Resident #1's wheelchair and as the wheelchair was turning Resident #1 grabbed the side rail and CNA A pulled Resident #1 out of the wheelchair. Restorative Aide A stated she saw it as she was coming into the side door and saw that the transfer was not going to end well. Restorative Aide A stated she went to try to stop Resident #1 and pull her (Resident #1) back, but Resident #1 was scooted herself to the edge of the wheelchair on her bottom. Restorative Aide A stated the staff usually make made sure Resident #1 is was sitting all the way back in the wheelchair before they turned the resident. Restorative Aide A stated when she saw Resident #1, she was on the edge of her wheelchair and CNA A was turning Resident #1's wheelchair and she (Resident #1) grabbed hold of the rail in the hallway . Restorative Aide A stated Resident #1 was already sitting forward in the wheelchair, and she did not think CNA A realized it because other residents were talking to her. Restorative Aide A stated she could not get to the door fast enough to tell CNA A not to move Resident #1. In a telephone interview on 4/20/23 at 1:15 p.m. with CNA A she stated Resident #1 was in her wheelchair on the men's side of the hall on 4/17/23, and CNA A stated she was getting ready to take her trash outside. CNA A stated she went to grab Resident #1's wheelchair and she did not turn Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675344 If continuation sheet Page 2 of 7 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 04/20/2023 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 0689 Level of Harm - Actual harm Residents Affected - Few #1 fast, Resident #1 went forward to reach to reach for the white rail on the hallway and fell out of the wheelchair and Resident #1 hit her head. CNA A stated she put a towel on Resident #1's head because she started bleeding. CNA A stated Resident #1 was sitting up in her wheelchair, like she normally did, with her legs crossed. CNA A stated when she moved Resident #1, she (Resident #1) uncrossed her legs and put her feet down to stop herself from being moved. CNA A stated she told Resident #1 she was going to turn her. CNA A stated Resident #1 was not sitting all the way back in her wheelchair. CNA A explained Resident #1 sat halfway in the wheelchair and the staff try tried to sit Resident #1 back, but she sits sat halfway and Resident #1's behind is was in the middle of the wheelchair . CNA A stated she had been working at the facility since December 2022 and she was trained in transferring residents. CNA A stated she had been a CNA for almost 6 years. CNA A stated Resident #1 should have been sitting all the way back in the wheelchair before she (CNA A) moved her. CNA A stated the Nurse that who assisted Resident #1 was Charge Nurse A. In an observation and interview on 4/20/23 at 1:25 p.m. with Resident #1, she was observed sitting in a wheelchair at the dining table and observation revealed a bruise on the left side of her face, dark in color, bruises on her left forearm, right arm and a cut by Resident #1's eyebrow. Observation revealed Resident #1 was sitting all the way back in her wheelchair with her legs crossed. Resident #1 stated that she did not want to talk, and she stated that she was not going. Resident #1 appeared to be very confused. In an interview on 4/20/23 at 1:30 p.m. with LVN A, she stated when Resident #1 moved around in her wheelchair, using her legs to move her wheelchair, Resident #1 will would scoot to the edge of the wheelchair. LVN A stated if Resident #1 is was in crying mode (she cries a lot), she (Resident #1) would scoot to the edge of her wheelchair. LVN A stated it took one person to transfer Resident #1 and the staff usually encouraged Resident #1 to sit back in the wheelchair. LVN A stated Resident #1 just scoots scooted by herself and inches to the edge of or leans leaned forward in the wheelchair. In an interview on 4/20/23 at 1:37 p.m. with the ADON she stated Resident #1 had a witnessed fall on the hallway and a CNA A was involved. The ADON stated Resident #1 was always crying, confused, and trying tried to get up from the wheelchair. In an interview on 4/20/23 at 1:50 p.m. with Charge Nurse B, he stated the facility did not report Resident #1's fall because there was no fracture and because the staff told him that Resident #1 was trying to get up from her wheelchair and he told the staff to write statements and make made sure to put it in their paperwork. Charge Nurse BA stated he got statements from CNA A, but they had Charge Nurse A to do the documentation, not the CNA. Charge Nurse BA stated the facility did not have the CNA's to write notes of what happened. Charge Nurse B stated Resident #1 hit her head and they sent her out to the hospital, but they did not make a report to the state. In an interview on 4/20/23 at 2:04 p.m. with Charge Nurse A, she stated she did not see the fall of Resident #1, but CNA A came to get her (Charge Nurse A) and stated Resident #1 had a fall. Charge Nurse A stated she went to assess Resident #1 and assist her, and she (Charge Nurse A) took a statement from CNA A. Charge Nurse A stated CNA A stated she was assisting Resident #1 stay seated in the wheelchair and Resident #1 grabbed the side rail. This Surveyor did inform Charge Nurse A of the statements of those who witnessed the fall stating that Resident #1 was not sitting back in the wheelchair when CNA A moved Resident #1 in her wheelchair and when CNA A turned Resident #1 she (Resident#1) leaned forward to grab the handrail in the hallway and fell. Charge Nurse A stated the statement sounded about right. Charge Nurse A stated she took the statement from CNA A and she stated when CNA A was moving Resident #1 in her wheelchair she was not sitting back and she was turning Resident #1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675344 If continuation sheet Page 3 of 7 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 04/20/2023 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 0689 Level of Harm - Actual harm Residents Affected - Few and she leaned forward in the wheelchair to grab the rail and Resident #1 fell out the wheelchair. This Surveyor did ask Charge Nurse A why she did not write the complete statement of Resident #1's fall, Charge Nurse A stated she did not write the complete statement of Resident #1's fall because she got busy. Charge Nurse A stated when she writes wrote the resident notes it is was very important to write all the details, but she was in the middle of a lot of different things so that is what happened . In an attempted interview on 4/20/23 at 2:20 p.m. with the Administrator when this the State Surveyor asked how important it was to document she deferred answering the question to the Regional Nurse. In an interview on 4/20/23 at 2:23 p.m. with the Regional Nurse, he stated that documentation was very important they have had to paint the entire picture. The Regional Nurse stated if the staff was were not present for the incident, they have had to document the statements and that is was the only way to protect yourself and your license. The Regional Nurse stated if the resident was already on in the wheelchair, they have had to make sure the resident is was properly seated on in the wheelchair before rolling the resident down the hallway to prevent the resident from falling. Record review of the facility's policy on Transfers and Lifting-Physical, revised 8/2019, revealed, It is the policy of this facility to provide a safe and efficient transfer of residents and the protection of the caregiver from injury during transport. Record review of the facility's policy on Fall Management, revised 1/2019, revealed, Purpose . To gather accurate, objective, and consistent data for the purpose of implementing an individualized Plan of Care designated to meet the resident's needs. To ensure consistency in the implementation of preventive measures to assist with the reduction of falls .To evaluate outcomes. Record review of the facility's policy on Abuse, Neglect, & Exploitation Prevention Policy & Procedure, revised 9-10-2020 revealed, Our facility prohibits the abuse, mistreatment, neglect, and/or exploitation of residents .Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675344 If continuation sheet Page 4 of 7 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 04/20/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 1 of 5 residents Resident #1) whose records were reviewed for accuracy and completeness in that: -The facility failed to completely and accurately document Resident#1's change in condition and transfer to the local hospital. -The facility failed to completely and accurately document Resident #1's Progress note for Resident #1's fall. This failure placed residents at risk of having incomplete and inaccurate records. Findings include: Record review of Resident #1's face sheet, dated 4/20/23, revealed the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #1 was a [AGE] year-old female with diagnoses which included dementia with unspecified severity, without other behavioral disturbance (lose the ability to think/no behaviors), anxiety, fever, osteomyelitis (bone infection), delusional disorders (person can't tell what's real), vitamin D deficiency, repeated falls, laceration without foreign body of left forearm, pressure ulcer of right ankle, unstageable, pressure ulcer of left ankle, unstageable, constipation, non-pressure chronic ulcer of other part of right food with unspecified severity, cellulitis of right lower limb (bacterial infection) and edema (fluid in tissue). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS summary score of 3, which indicated Resident #1's cognition was severely impacted. Resident #1's Activities of Daily Living Assistance revealed walking in room, and corridor did not occur, bed mobility, transfer, dressing, and personal hygiene required extensive assistance with one personal physical assistance. Resident #1 did not transfer from toilet, or walking, sit to stand and chair/bed-to-chair transfer was substantial/maximal assistance and lying to sitting on side of bed, sit to lying and roll left and right was partial/moderate assistance. Active diagnosis were hip fracture, other fracture, non-Alzheimer's dementia (Memory Impairment not caused by Alzheimer's), and repeated falls. Record review of Resident #1's, undated, Care Plan revealed [Resident #1] was at risk for falls and injuries; Goal: [Resident #1] will be free from further falls and injuries over the next 90 days. Intervention: Anticipate needs provide prompt assistance, assure lighting is adequate and areas are free of clutter, ensure call light is within reach and answer promptly and keep frequently used items at resident beside. [Resident #1] is at risk for falls related to poor balance, Poor communication/comprehension, Unsteady gait. Interventions .For no apparent acute injury, determine and address causative factors of the fall. Record review of Resident #1's SBAR (Change of Condition), dated 4/17/23 at 1:51 p.m., revealed, Witnessed fall, Assessment- What do you think is going on with the resident? Confused, RecommendationMonitor vital signs and transfer to hospital. Physician notified and POA, ER Contact or Responsible Party notified on 4/17/23 at 1:30 p.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675344 If continuation sheet Page 5 of 7 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 04/20/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #1's Progress Notes, dated 4/18/23 at 1:39 p.m., written by ADON, revealed Resident attempting to get out of wheelchair. Staff went over to assist resident and as resident grabbed the handlebar on the wall, she slipped and fell from her chair. Resident hit left side of her face on the floor and also received a skin tear to her left hand. In an interview on 4/20/23 at 12:35 p.m. with Restorative Aide A she stated she witnessed the fall of Resident #1 on the Memory Care Unit (She could not recall the date). Restorative Aide A stated CNA A went to turn Resident #1's wheelchair and as the wheelchair was turning Resident #1 grabbed the side rail and CNA A pulled Resident #1 out of the wheelchair. Restorative Aide A stated she saw it as she was coming into the side door and saw the transfer was not going to end well. Restorative Aide A stated she went to try to stop Resident #1 and pull her (Resident #1) back, but Resident #1 scooted herself to the edge of the wheelchair on her bottom. Restorative Aide A stated the staff usually made sure Resident #1 was sitting all the way back in the wheelchair before they turned the resident. Restorative Aide A stated when she saw Resident #1, she was on the edge of her wheelchair and CNA A was turning Resident #1's wheelchair and she (Resident #1) grabbed hold of the rail in the hallway. Restorative Aide A stated Resident #1 was already sitting forward in the wheelchair, and she did not think CNA A realized it because other residents were talking to her. Restorative Aide A stated she could not get to the door fast enough to tell CNA A not to move Resident #1. In a telephone interview on 4/20/23 at 1:15 p.m. with CNA A she stated Resident #1 was in her wheelchair on the men's side of the hall on 4/17/23, and CNA A stated she was getting ready to take her trash outside. CNA A stated she went to grab Resident #1's wheelchair and she did not turn Resident #1 fast, Resident #1 went forward to reach for the white rail on the hallway and fell out of the wheelchair and Resident #1 hit her head. CNA A stated she put a towel on Resident #1's head because she started bleeding. CNA A stated Resident #1 was sitting up in her wheelchair, like she normally did, with her legs crossed. CNA A stated when she moved Resident #1, she (Resident #1) uncrossed her legs and put her feet down to stop herself from being moved. CNA A stated she told Resident #1 she was going to turn her. CNA A stated Resident #1 was not sitting all the way back in her wheelchair. CNA A explained Resident #1 sat halfway in the wheelchair and the staff tried to sit Resident #1 back, but she sat halfway and Resident #1's behind was in the middle of the wheelchair. CNA A stated she had been working at the facility since December 2022 and she was trained in transferring residents. CNA A stated she had been a CNA for almost 6 years. CNA A stated Resident #1 should have been sitting all the way back in the wheelchair before she (CNA A) moved her. CNA A stated the Nurse who assisted Resident #1 was Charge Nurse A. In an observation and interview on 4/20/23 at 1:25 p.m. with Resident #1, she was observed sitting in a wheelchair at the dining table and observation revealed a bruise on the left side of her face, dark in color, bruises on her left forearm, right arm and a cut by Resident #1's eyebrow. Observation revealed Resident #1 was sitting all the way back in her wheelchair with her legs crossed. Resident #1 stated she did not want to talk, and she stated she was not going. Resident #1 appeared to be very confused. In an interview on 4/20/23 at 1:30 p.m. with LVN A, she stated when Resident #1 moved around in her wheelchair, using her legs to move her wheelchair, Resident #1 would scoot to the edge of the wheelchair. LVN A stated if Resident #1 was in crying mode (she cries a lot), she (Resident #1) would scoot to the edge of her wheelchair. LVN A stated it took one person to transfer Resident #1 and the staff usually encouraged Resident #1 to sit back in the wheelchair. LVN A stated Resident #1 just scooted by herself and inches to the edge of or leaned forward in the wheelchair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675344 If continuation sheet Page 6 of 7 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 04/20/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 4/20/23 at 2:04 p.m. with Charge Nurse A, she stated she did not see the fall of Resident #1, but CNA A came to get her (Charge Nurse A) and stated Resident #1 had a fall. Charge Nurse A stated she went to assess Resident #1 and assist her, and she (Charge Nurse A) took a statement from CNA A. Charge Nurse A stated CNA A stated she was assisting Resident #1 stay seated in the wheelchair and Resident #1 grabbed the side rail. Charge Nurse A stated she took the statement from CNA A and she stated when CNA A was moving Resident #1 in her wheelchair she was not sitting back and she was turning Resident #1 and she leaned forward in the wheelchair to grab the rail and Resident #1 fell out the wheelchair. Charge Nurse A stated she did not write the complete statement of Resident #1's fall because she got busy. Charge Nurse A stated when she wrote the resident notes it was very important to write all the details, but she was in the middle of a lot of different things. In an attempted interview on 4/20/23 at 2:20 p.m. with the Administrator when the State Surveyor asked how important it was to document she deferred answering the question to the Regional Nurse. In an interview on 4/20/23 at 2:23 p.m. with the Regional Nurse, he stated documentation was very important they had to paint the entire picture. The Regional Nurse stated if the staff were not present for the incident, they had to document the statements and that was the only way to protect yourself and your license. No facility policy for documentation was received prior to exit. Record review of https://www.myshepherdconnection.org/sci/wheelchair-positioning, undated revealed, Key points for positioning: Hips/pelvis: This is the base or foundation of sitting. This area should be checked first, Bottom all the way back in chair, Centered within confines of the wheelchair, Top of pelvis should be level (left even with right), Knees should be even, Trunk or chest, Positioned in the middle of the backrest without leaning to one side . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675344 If continuation sheet Page 7 of 7