Inspection·August 30, 2023

F 0607 Level of Harm - Minimal harm or potential for actual harm Record review of CNA A statement (undated) indicated CNA A noticed a dark spot on Resident #1 right cheek (buttocks) near her anus on 03/27/23. CNA A did not report the bruise to the charge nurse, DON, or administrator. CNA A was no longer employed with the facility. The surveyor was not able to make contact. Residents Affected - Some Record review of CNA B's statement dated 04/01/23 indicated CNA B noticed a sore on Resident #1's buttocks on 03/29/23 and did not report to a nurse, the DON, or the administrator. The surveyor attempted to contact CNA B on 08/30/23 at 2:21 p.m. A voicemail message was left with contact information. There was no response. Record review of CNA C's statement dated 04/01/23 indicated he saw bruising on Resident #1's anus on 03/30/23. He indicated Resident #1 did not know the bruise was there or how she sustained the bruise. CNA C indicated he did not remember to report the bruise to his charge nurse. The surveyor attempted to contact CNA C on 08/30/23 at 2:16 p.m. A voicemail message was left with contact information. There was no response. Record review of an SBAR for Change of Condition dated 04/01/23 at 5:38 a.m., and completed by LVN D indicated she was called to Resident #1's room by (staff). Bruises to the left perianal area and left labia were noted. The Administrator and DON were notified. Resident #1 stated she sat on the arm of a wheelchair a few days ago. During an interview on 08/25/23 at 01:28 p.m., the administrator said she was made immediately made aware of the incident on 04/01/23 when nurse staff were made aware of Resident #1's bruise. She said the incident was not reported within two hours because it was thought it was possible Resident #1's (family member) might have had sex with his wife when she was out on pass. She said the incident was reviewed by corporate and deemed reportable on 04/01/23 and that was when she made the report to state. She said there was a problem with the electronic reporting website and the report did not go through until 04/03/23. She said staff were expected to report all injuries of unknown origin and bruises to the charge nurse immediately. She said staff were inserviced on 04/03/23 and 04/10/23 on reporting all wounds or bruises to the charge nurses and charge nurses were inserviced to report all wounds or injuries or unknown origin to the DON and administrator immediately. During an interview on 08/30/23 at 12:18 p.m., RN E (former DON) said she assessed Resident #1 on 04/01/23. She said she immediately discussed Resident #1's suspicious bruises to her perianal area and labia with the administrator. She said the administrator made the decision the bruises were not reportable but she could not recall the reason for the decision. She said all suspicious bruises should have been reported to the charge nurse, the DON, and the administrator immediately. She said the ultimate decision was made between the administrator and the RDO. She said staff were expected to report all injuries of unknown origin and bruises to the charge nurse immediately She said staff were inserviced on 04/03/23 and 04/10/23 on reporting all wounds or bruises to the charge nurses and charge nurses were inserviced to report all wounds or injuries of unknown origin to the DON and administrator immediately. The surveyor attempted to contact LVN D on 08/30/23 at 2:31 p.m. and left a message with contact (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675391 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 675391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656 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 0607 information. LVN D did not respond. Level of Harm - Minimal harm or potential for actual harm Record review of a face sheet dated 08/25/23 indicated Resident #2 was an [AGE] year-old female, admitted on [DATE], and her diagnoses included moderate dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with behavioral disturbances, pseudobulbar affect (episodes of sudden uncontrollable and inappropriate laughing or crying), and anxiety (feeling of fear, dread, and uneasiness). Residents Affected - Some Record review of an MDS assessment dated [DATE] indicated Resident #2 was able to make herself understood and was able to understand others, had a BIMS of 10 (moderate cognitive impairment), and required supervision for all ADLS. Record review of a progress note dated 05/27/23 at 11:44 a.m., completed by LVN F indicated Resident #2 reported a male resident (Resident #5) hit her on the right side of the face when she walked by. Resident #2 changed her story from the dining room to her bedroom after talking with MS G and (LVN F). Record review of a progress note dated 05/27/23 at 12:04 p.m., completed by LVN F indicated Resident #2 had no redness to her face or obvious injury noted. Record review of a face sheet dated 08/25/23 indicated resident #5 was a [AGE] year-old male, admitted on [DATE], and his diagnoses included alcohol induced persisting dementia (alcohol abuse is determined to be the most likely cause of the dementia symptoms), delusional disorders (unshakable beliefs in something that isn't true or based on reality), and unspecified psychosis (no one cause of psychosis). Record review of an MDS assessment dated [DATE] indicated he was usually able to make himself understood and usually understood others, he had a BIMS score of 3 (severe cognitive impairment), required extensive assist for most ADLS, and utilized a wheelchair for mobility. Record review of a care plan dated 02/17/20 indicated Resident #2 had a behavior problem and has shown aggressive behavior at times. Interventions included observe behavior episodes and attempt to determine underlying cause. Record review of a progress note dated 05/27/23 at 12:01 p.m., competed by LVN F indicated Resident #5 shrugged his shoulders when asked if he hit Resident #2. Resident #5 did not confirm or deny he hit Resident #2. During an interview on 08/25/23 at 10:30 a.m., Resident #2 could not recall any incident of being hit by any resident. She said she had no problems with any residents being mean or hitting her. During an interview on 08/25/23 at 10:45 a.m., Resident #5 could not recall any issues with any residents. He requested pain medication for his shoulder. During an interview on 08/25/23 at 01:28 p.m., the administrator said she was immediately made aware of the incident on 05/27/23 after Resident #2 alleged Resident #5 slapped her face. She said the incident was not reported within two hours because Resident #2 had varying statements. She said Resident #5 would not confirm or deny when asked if the incident occurred. She said the incident was reviewed at the corporate level and the facility was directed to report the incident on 06/06/23. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675391 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 675391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656 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 0607 Level of Harm - Minimal harm or potential for actual harm said all allegations of abuse were reportable within two hours but she could not recall why she did not report when Resident #2 alleged Resident #5 slapped her face. During an interview on 08/29/23 at 2:08 p.m., MS G said he could not recall the incident of Resident #5 slapping Resident #2. Residents Affected - Some During an interview on 08/30/23 at 12:18 p.m., RN E (former DON) said she did not believe when Resident #5 slapped Resident #2 was reportable because both residents had dementia. She said the RDO reviewed the incident and made the decision it was reportable. The surveyor attempted to contact LVN F on 08/30/23 at 2:30 p.m. A voicemail message was left with contact information. There was no response. Record review of a face sheet dated 08/30/23 indicated Resident #3 was a [AGE] year-old female, admitted on [DATE], and her diagnoses included Huntington's (an inherited disorder that causes nerve cells (neurons) in parts of the brain to gradually break down and die), adjustment disorder (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior), and unspecified psychosis. Record review of an MDS assessment dated [DATE] indicated Resident #3 was usually understood and was usually able to understand others, had a BIMS score of 9 (moderate cognitive impairment), required supervision and limited assist with most ADLS. Record review of a progress noted dated 06/02/23 at 1:03 p.m., completed by LVN H indicated Resident #3 was sitting by the nurse station when she was grabbed in the thigh and peri area by Resident #5. Resident #3 was assessed and no skin issues were noted. Record review of the facility investigation dated 06/10/23 indicated MS G witnessed Resident #5 grab Resident #3's inner thigh. During an interview on 08/29/23 at 1:14 p.m., LVN H said Resident #5 was being aggressive with staff and grabbing staff. She said he grabbed Resident #3's inner thigh and peri area. She said he was taken to his room by MS G. She said Resident #3 was angry. She said Resident #3 had no injuries. She said she notified the DON immediately. During an interview on 08/29/23 at 1:32 p.m., the administrator said she could not recall when she was made aware of the incident when Resident #5 grabbed Resident #3's thigh. She said Resident #5 was placed on 1 to 1 supervision and sent out to behavior hospital on [DATE]. She said she did not report the incident to the state but could not recall the reason she believed the incident was not reportable. She said corporate reviewed the incident and directed her to report to state on 06/06/23. She said staff were to notify the administrator or designee immediately of all allegations of abuse or neglect. She said she was required to report all allegations of abuse or neglect to the state within two hours. During an interview on 08/29/23 at 1:45 p.m., Resident #3 said she was mad when Resident #5 grabbed her thigh. She said there was no previous incident and there were no further incidents. She said she was not afraid of Resident #5 or any other resident. During an interview on 08/29/23 at 2:08 p.m., MS G said he witnessed Resident #5 grab Resident #3's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675391 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 675391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some inner thigh (crotch) area. He said Resident #3 was wearing shorts. He said Resident #3 got mad. He said she was sitting by the nurse station. He said Resident #5 was acting like he was going to hit Resident #3 so he moved Resident #5 away from the Resident #3 and got a nurse. He said he could not recall the nurse's name. During an interview on 08/29/23 at 3:17 p.m., LVN I said she was on-call on 06/02/23 when Resident #5 grabbed Resident #3's thigh area. She said LVN J called her and informed her of the incident. She said she directed staff to separate the residents and call the physician for orders to send Resident #5 to behavior hospital. She said Resident #5 had behaviors of grabbing and being aggressive with staff but not with residents. She said she reported the incident to the administrator immediately on 06/02/23 but could not recall the exact time. During an interview on 08/29/23 at 3:08 p.m., SW J said she was informed Resident #5 grabbed Resident #3's inner thigh. She said Resident #3 was touched inappropriately. She said she discussed the incident with Resident #3 and she felt safe. Resident #5 said nothing occurred and she did not want to press charges. Resident #5 was sent out to a behavior hospital immediately. During an interview on 08/29/23 at 3:53 p.m., the ADON said she could not recall when she was told Resident #5 grabbed Resident #3's inner thigh. She said all allegations of abuse should be reported to the administrator or designee immediately. She said all allegations of abuse were supposed to be reported to the state within two hours. She said she did not know why the incident was not reported as required. During an interview on 08/30/23 at 12:18 p.m., RN E (former DON) said she was made aware of the incident immediately on 06/02/23 when Resident #5 grabbed Resident #3's inner thigh. She said she discussed the incident immediately with the administrator. She said the administrator said the incident was not reportable. She said the incident was reviewed by corporate and it was determined the incident was reportable. Record review of the facility's Nursing Policies and Procedures- Abuse/Neglect revised June 2019 indicated It is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. Abuse the will infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.Instance of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse including facilitated or enabled though the use of technology. Will, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The administrator is the abuse coordinator in this facility, and is responsible for developing and implementing the abuse prevention training curriculum and conducting the investigation in situations of alleged abuse/neglect. Physical abuse includes but is not limited to infliction of injury that occur other than by accidental means examples: hitting, slapping, .Any person my potentially cause harm to a resident. Potential aggressors include but are not limited to, facility staff, other residents, state employees, family members, guardian and other visitors.If abuse/neglect is suspected the facility will: 1. Take immediate steps to assure the protection of the resident(s). This may involve separations of the alleged abuser and/or provision of medical care. 2. The facility shall report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675391 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 675391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656 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 0607 injury to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675391 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 675391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury for 4 of 16 residents (Resident #s 1, 2, 3, and 5) reviewed for abuse and neglect. The facility failed to ensure the abuse coordinator and/or designee reported immediately to HHSC after: they were made aware of suspicious bruises to Resident #1's perianal area, Resident #2 alleged Resident #5 slapped her face, and Resident #5 grabbed Resident #3's inner thigh. These failures could place residents at risk of emotional, physical, and mental abuse. Findings included: Record review of a face sheet dated 08/30/23 indicated Resident #1 was an [AGE] year-old female, admitted on [DATE], and her diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, abnormities of gait and mobility (unable to walk in the usual way), and memory deficit following cerebral infarction (unusual forgetfulness). Record review of an MDS assessment dated [DATE] indicated Resident #1 was able to make herself understood and able to understand others, had a BIMS of 5 (severe cognitive impairment) and required extensive to total physical assist for most ADLS. She utilized a wheelchair for mobility. Record review of progress note dated 05/24/23 at 4:02 p.m., completed by LVN K indicated Resident #1 was discharged from the facility on 05/24/23. She was not observed or interviewed. Record review of the facility investigation submitted 04/10/23 indicated the facility was made aware of the bruises to Resident #1's perianal area on 04/01/23. The facility did not report the suspicious bruises until 04/03/23 (due to issues with electronic reporting system, the initial report on 04/01/23 was not submitted). Record review of CNA A statement (undated) indicated CNA A noticed a dark spot on Resident #1 right cheek (buttocks) near her anus on 03/27/23. CNA A did not report the bruise to the charge nurse, DON, or administrator. CNA A was no longer employed with the facility. The surveyor was not able to make contact. Record review of CNA B's statement dated 04/01/23 indicated CNA B noticed a sore on Resident #1's buttocks on 03/29/23 and did not report to a nurse, the DON, or the administrator. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675391 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 675391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The surveyor attempted to contact CNA B on 08/30/23 at 2:21 p.m. A voicemail message was left with contact information. There was no response. Record review of CNA C's statement dated 04/01/23 indicated he saw bruising on Resident #1's anus on 03/30/23. He indicated Resident #1 did not know the bruise was there or how she sustained the bruise. CNA C indicated he did not remember to report the bruise to his charge nurse. The surveyor attempted to contact CNA C on 08/30/23 at 2:16 p.m. A voicemail message was left with contact information. There was no response. Record review of an SBAR for Change of Condition dated 04/01/23 at 5:38 a.m., and completed by LVN D indicated she was called to Resident #1's room by (staff). Bruises to the left perianal area and left labia were noted. The Administrator and DON were notified. Resident #1 stated she sat on the arm of a wheelchair a few days ago. During an interview on 08/25/23 at 01:28 p.m., the administrator said she was made immediately made aware of the incident on 04/01/23 when nurse staff were made aware of Resident #1's bruise. She said the incident was not reported within two hours because it was thought it was possible Resident #1's (family member) might have had sex with his wife when she was out on pass. She said the incident was reviewed by corporate and deemed reportable on 04/01/23 and that was when she made the report to state. She said there was a problem with the electronic reporting website and the report did not go through until 04/03/23. She said staff were expected to report all injuries of unknown origin and bruises to the charge nurse immediately. She said staff were inserviced on 04/03/23 and 04/10/23 on reporting all wounds or bruises to the charge nurses and charge nurses were inserviced to report all wounds or injuries or unknown origin to the DON and administrator immediately. During an interview on 08/30/23 at 12:18 p.m., RN E (former DON) said she assessed Resident #1 on 04/01/23. She said she immediately discussed Resident #1's suspicious bruises to her perianal area and labia with the administrator. She said the administrator made the decision the bruises were not reportable but she could not recall the reason for the decision. She said all suspicious bruises should have been reported to the charge nurse, the DON, and the administrator immediately. She said the ultimate decision was made between the administrator and the RDO. She said staff were expected to report all injuries of unknown origin and bruises to the charge nurse immediately She said staff were inserviced on 04/03/23 and 04/10/23 on reporting all wounds or bruises to the charge nurses and charge nurses were inserviced to report all wounds or injuries of unknown origin to the DON and administrator immediately. The surveyor attempted to contact LVN D on 08/30/23 at 2:31 p.m. and left a message with contact information. LVN D did not respond. Record review of a face sheet dated 08/25/23 indicated Resident #2 was an [AGE] year-old female, admitted on [DATE], and her diagnoses included moderate dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with behavioral disturbances, pseudobulbar affect (episodes of sudden uncontrollable and inappropriate laughing or crying), and anxiety (feeling of fear, dread, and uneasiness). Record review of an MDS assessment dated [DATE] indicated Resident #2 was able to make herself (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675391 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 675391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some understood and was able to understand others, had a BIMS of 10 (moderate cognitive impairment), and required supervision for all ADLS. Record review of a progress note dated 05/27/23 at 11:44 a.m., completed by LVN F indicated Resident #2 reported a male resident (Resident #5) hit her on the right side of the face when she walked by. Resident #2 changed her story from the dining room to her bedroom after talking with MS G and (LVN F). Record review of a progress note dated 05/27/23 at 12:04 p.m., completed by LVN F indicated Resident #2 had no redness to her face or obvious injury noted. Record review of a face sheet dated 08/25/23 indicated resident #5 was a [AGE] year-old male, admitted on [DATE], and his diagnoses included alcohol induced persisting dementia (alcohol abuse is determined to be the most likely cause of the dementia symptoms), delusional disorders (unshakable beliefs in something that isn't true or based on reality), and unspecified psychosis (no one cause of psychosis). Record review of an MDS assessment dated [DATE] indicated he was usually able to make himself understood and usually understood others, he had a BIMS score of 3 (severe cognitive impairment), required extensive assist for most ADLS, and utilized a wheelchair for mobility. Record review of a care plan dated 02/17/20 indicated Resident #2 had a behavior problem and has shown aggressive behavior at times. Interventions included observe behavior episodes and attempt to determine underlying cause. Record review of a progress note dated 05/27/23 at 12:01 p.m., competed by LVN F indicated Resident #5 shrugged his shoulders when asked if he hit Resident #2. Resident #5 did not confirm or deny he hit Resident #2. During an interview on 08/25/23 at 10:30 a.m., Resident #2 could not recall any incident of being hit by any resident. She said she had no problems with any residents being mean or hitting her. During an interview on 08/25/23 at 10:45 a.m., Resident #5 could not recall any issues with any residents. He requested pain medication for his shoulder. During an interview on 08/25/23 at 01:28 p.m., the administrator said she was immediately made aware of the incident on 05/27/23 after Resident #2 alleged Resident #5 slapped her face. She said the incident was not reported within two hours because Resident #2 had varying statements. She said Resident #5 would not confirm or deny when asked if the incident occurred. She said the incident was reviewed at the corporate level and the facility was directed to report the incident on 06/06/23. She said all allegations of abuse were reportable within two hours but she could not recall why she did not report when Resident #2 alleged Resident #5 slapped her face. During an interview on 08/29/23 at 2:08 p.m., MS G said he could not recall the incident of Resident #5 slapping Resident #2. During an interview on 08/30/23 at 12:18 p.m., RN E (former DON) said she did not believe when Resident #5 slapped Resident #2 was reportable because both residents had dementia. She said the RDO reviewed the incident and made the decision it was reportable. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675391 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 675391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The surveyor attempted to contact LVN F on 08/30/23 at 2:30 p.m. A voicemail message was left with contact information. There was no response. Record review of a face sheet dated 08/30/23 indicated Resident #3 was a [AGE] year-old female, admitted on [DATE], and her diagnoses included Huntington's (an inherited disorder that causes nerve cells (neurons) in parts of the brain to gradually break down and die), adjustment disorder (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior), and unspecified psychosis. Record review of an MDS assessment dated [DATE] indicated Resident #3 was usually understood and was usually able to understand others, had a BIMS score of 9 (moderate cognitive impairment), required supervision and limited assist with most ADLS. Record review of a progress noted dated 06/02/23 at 1:03 p.m., completed by LVN H indicated Resident #3 was sitting by the nurse station when she was grabbed in the thigh and peri area by Resident #5. Resident #3 was assessed and no skin issues were noted. Record review of the facility investigation dated 06/10/23 indicated MS G witnessed Resident #5 grab Resident #3's inner thigh. During an interview on 08/29/23 at 1:14 p.m., LVN H said Resident #5 was being aggressive with staff and grabbing staff. She said he grabbed Resident #3's inner thigh and peri area. She said he was taken to his room by MS G. She said Resident #3 was angry. She said Resident #3 had no injuries. She said she notified the DON immediately. During an interview on 08/29/23 at 1:32 p.m., the administrator said she could not recall when she was made aware of the incident when Resident #5 grabbed Resident #3's thigh. She said Resident #5 was placed on 1 to 1 supervision and sent out to behavior hospital on [DATE]. She said she did not report the incident to the state but could not recall the reason she believed the incident was not reportable. She said corporate reviewed the incident and directed her to report to state on 06/06/23. She said staff were to notify the administrator or designee immediately of all allegations of abuse or neglect. She said she was required to report all allegations of abuse or neglect to the state within two hours. During an interview on 08/29/23 at 1:45 p.m., Resident #3 said she was mad when Resident #5 grabbed her thigh. She said there was no previous incident and there were no further incidents. She said she was not afraid of Resident #5 or any other resident. During an interview on 08/29/23 at 2:08 p.m., MS G said he witnessed Resident #5 grab Resident #3's inner thigh (crotch) area. He said Resident #3 was wearing shorts. He said Resident #3 got mad. He said she was sitting by the nurse station. He said Resident #5 was acting like he was going to hit Resident #3 so he moved Resident #5 away from the Resident #3 and got a nurse. He said he could not recall the nurse's name. During an interview on 08/29/23 at 3:17 p.m., LVN I said she was on-call on 06/02/23 when Resident #5 grabbed Resident #3's thigh area. She said LVN J called her and informed her of the incident. She said she directed staff to separate the residents and call the physician for orders to send Resident #5 to behavior hospital. She said Resident #5 had behaviors of grabbing and being aggressive with staff but not with residents. She said she reported the incident to the administrator immediately on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675391 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 675391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656 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 0609 06/02/23 but could not recall the exact time. Level of Harm - Minimal harm or potential for actual harm During an interview on 08/29/23 at 3:08 p.m., SW J said she was informed Resident #5 grabbed Resident #3's inner thigh. She said Resident #3 was touched inappropriately. She said she discussed the incident with Resident #3 and she felt safe. Resident #5 said nothing occurred and she did not want to press charges. Resident #5 was sent out to a behavior hospital immediately. Residents Affected - Some During an interview on 08/29/23 at 3:53 p.m., the ADON said she could not recall when she was told Resident #5 grabbed Resident #3's inner thigh. She said all allegations of abuse should be reported to the administrator or designee immediately. She said all allegations of abuse were supposed to be reported to the state within two hours. She said she did not know why the incident was not reported as required. During an interview on 08/30/23 at 12:18 p.m., RN E (former DON) said she was made aware of the incident immediately on 06/02/23 when Resident #5 grabbed Resident #3's inner thigh. She said she discussed the incident immediately with the administrator. She said the administrator said the incident was not reportable. She said the incident was reviewed by corporate and it was determined the incident was reportable. Record review of the facility's Nursing Policies and Procedures- Abuse/Neglect revised June 2019 indicated It is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. Abuse the will infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.Instance of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse including facilitated or enabled though the use of technology. Will, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The administrator is the abuse coordinator in this facility, and is responsible for developing and implementing the abuse prevention training curriculum and conducting the investigation in situations of alleged abuse/neglect. Physical abuse includes but is not limited to infliction of injury that occur other than by accidental means examples: hitting, slapping, .Any person my potentially cause harm to a resident. Potential aggressors include but are not limited to, facility staff, other residents, state employees, family members, guardian and other visitors.If abuse/neglect is suspected the facility will: 1. Take immediate steps to assure the protection of the resident(s). This may involve separations of the alleged abuser and/or provision of medical care. 2. The facility shall report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675391 If continuation sheet Page 11 of 11