Health inspection·September 20, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure assessments accurately reflected the resident status for 5 of 5 residents (Residents #9, #18, #31, #40, and #58) reviewed for MDS assessment accuracy. Residents Affected - Some The facility did not ensure Residents #9, #18, #31, #40, and #58 assessment was accurately coded to reflect falls since the previous assessment. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: 1. Record review of a face sheet dated 09/20/23 indicated Resident #9 was a [AGE] year-old female admitted on [DATE]. Record review of Incident Reports Log for 04/23 through 09/23 indicated Resident #9 had a fall on 04/13/23. Record review of an MDS dated [DATE] for Resident #9 indicated it was incorrectly marked as she had 2+ falls since the last assessment. Record review of Resident #9's MDSs indicated her last assessment prior to 06/20/23 was 04/06/23. Record review of the care plan dated 11/17/22 for Resident #9 indicated it was updated with the fall on 04/13/23. 2. Record review of a face sheet dated 09/20/23 indicated Resident #18 was a [AGE] year-old female admitted on [DATE]. Record review of Incident Reports Log for 04/23 through 09/23 indicated Resident #18 had a fall on 04/06/23. Record review of an MDS dated [DATE] for Resident #18 indicated it was incorrectly marked no for falls since prior assessment. Record review of Resident #18's MDSs indicated her last assessment prior to 04/16/23 was 01/14/23. Record review of the care plan dated 11/17/22 for Resident #18 indicated it was updated with the Page 1 of 24 675391 675391 09/20/2023 Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656

F 0641 fall on 04/06/23. Level of Harm - Minimal harm or potential for actual harm 3. Record review of a face sheet dated 09/20/23 indicated Resident #31 was a [AGE] year-old female admitted on [DATE]. Residents Affected - Some Record review of Incident Reports Log for 04/23 through 09/23 indicated Resident #31 had falls on 04/17/23 and 04/30/23. Record review of an MDS dated [DATE] for Resident #31 indicated it was incorrectly marked for 1 fall since her last assessment. Record review of Resident #31's MDSs indicated her last assessment prior to 09/20/23 was 04/05/23. Record review of Incident Reports Log for 04/23 through 09/23 indicated Resident #31 had falls on 05/08/23, 05/11/23, 05/12/23, and 05/23/23. Record review of an MDS dated [DATE] for Resident #31 indicated it was incorrectly marked for 1 fall since last assessment. Record review of Resident #31's MDSs indicated her last assessment prior to 06/14/23 was 05/02/23. Record review of the care plan dated 11/18/22 for Resident #31 indicated it was updated with the falls on 04/17/23, 04/30/23, 05/08/23, 05/11/23, 05/12/23, and 05/23/23. 4. Record review of a face sheet dated 09/20/23 indicated Resident #40 was an [AGE] year-old male admitted on [DATE]. Record review of Incident Reports Log for 04/23 through 09/23 indicated Resident #40 had a fall on 06/12/23. Record review of an MDS dated [DATE] for Resident #40 indicated it was incorrectly marked no for falls since prior assessment. Record review of Resident #40's MDSs indicated his last assessment prior to 08/10/23 was 05/10/23. Record review of the care plan dated 01/20/22 for Resident #40 indicated it was updated with the fall on 06/12/23. 5. Record review of a face sheet dated 09/20/23 indicated Resident #58 was an [AGE] year-old male admitted on [DATE]. Record review of Incident Reports Log for 04/23 through 09/23 indicated Resident #58 had falls on 04/14/23 and 05/18/23. Record review of an MDS dated [DATE] for Resident #58 indicated it was incorrectly marked for 1 fall with injury since last assessment. Record review of Resident #58's MDSs indicated his last assessment prior to 06/10/23 was 03/10/23. 675391 Page 2 of 24 675391 09/20/2023 Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the fall care plan dated 03/16/23 for Resident #58 indicated it was updated with the falls on 04/14/23 and 05/18/23. During an interview and record review on 09/20/23 at 10:00 a.m. the MDS Nurse reviewed the residents' MDSs and said they were not coded accurately for the falls. She said it was her responsibility to ensure the information on the MDS was accurately coded or it would reflect inaccurate information on the resident and could cause their needs not to be met . She said she obtained the information from the incident report logs and just missed them. Record review of an MDS policy and procedure revised 06/19 indicated: POLICY: The interdisciplinary team will complete the MDS for each patient/resident as part of the RAI process to assure data accuracy for its state-specific version of such within the required timeframes according to applicable law and regulations. Each team member will note their liability for the accuracy of the data recorded by signing their name and identifying the MDS sections and questions to which they provided responses 675391 Page 3 of 24 675391 09/20/2023 Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who had mental illness or intellectual disability for 1 of 18 residents (Residents #54) reviewed for PASARR. The facility failed to notify the local mental health authority after Resident #54's significant change in mental illness diagnosis following a new diagnosis of psychosis. This failure could place residents requiring PASARR services at risk of not having their special needs assessed and met by the facility. Findings include: Record review of face sheet dated 09/20/23 indicated Resident #54 was a [AGE] year-old female who admitted on [DATE] with diagnoses including Huntington's disease (inherited disorder that cause nerve cells in the brain to breakdown and die) and an adjustment disorder with anxiety. The diagnosis related to unspecified psychosis not due to a substance or known physiological condition when Resident #54 was readmitted on [DATE]. Record review of a quarterly MDS dated [DATE] indicated Resident #54 was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The MDS indicated the resident had a BIMS score of 11 which indicated moderately impaired cognition and she had no behaviors which impacted other residents. The MDS indicated Resident #54 was not prescribed antipsychotic, antianxiety or antidepressant medications. Record review of a PASARR Level 1 completed on 03/29/23 indicated Resident #54 was negative for PASARR . Record review of a PASARR Level 1 completed on 05/26/23 indicated Resident #54 was positive for mental illness from the discharging psychiatric hospital. Record review of physician orders dated September 2023 indicated Resident #54 was to receive Risperdal (antipsychotic) 0.5 mg at bedtime related to psychosis with a start date of 05/26/23 Record review of the care plan dated 8/28/23 indicated Resident #54 received psychotropic medications related to behavior management; Huntington's interventions included monitoring for medication side effects, reorientation, and medication treatments. During an interview on 09/19/23 at 3:59 p.m., the MDS nurse said Resident #54's PASARR Level 1 dated 05/26/23 was not sent to the local mental health authority and should have been sent. The MDS nurse confirmed that Resident #54's PASARR Level 1 had not been sent by looking at the Simple LTC portal on her computer. She said the PASARR was sent to medical records, and was not given to her. She said they found it after surveyor intervention. The MDS nurse said she was responsible for notifying the local mental health authority when the residents received new diagnoses of mental illnesses. She said she had received training in PASARR. 675391 Page 4 of 24 675391 09/20/2023 Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview 09/20/23 at 11:00 a.m., the administrator said her expectation was for her staff to notify the local mental health authority as required. She said they review readmits in their daily meetings. She said the residents might not get services they need. The undated policy titled PASARR Documentation This policy is intended as a general guide for the PASARR process. Each facility develops a process for completion of the PASARR requirements as indicated by state specific policy and procedures. If the PASARR Level I screening indicates the individual may have an ID, DD, or MI diagnosis, follow the state-specific process for completion of the Level II evaluation.The facility must notify the state-designated mental health or intellectual disability authority promptly when a resident with MD or ID experiences a significant change in mental or physical status. 675391 Page 5 of 24 675391 09/20/2023 Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards 2 of 2 residents reviewed for smoking safety assessments and 7 of 7 residents reviewed for fall risk assessments. The facility did not have Smoking-Safety Screens completed for Residents #9, and #13. The facility did not have Fall Risk Assessments completed for Residents #9, #18, #29, #31, #40, #54, and #58 after they had a fall. These failures could place residents at risk of harm or injury and contribute to avoidable accidents. Findings included: 1. Record review of a face sheet dated 09/20/23 indicated Resident #9 was a [AGE] year-old female admitted on [DATE] . Record review of an annual MDS assessment dated [DATE] indicated Resident #9 was a smoker. Record review care plan dated 07/08/22 Indicated Resident #9 was at risk for injury related to smoking, also uses smokeless dipping tobacco. The unsafe smoker interventions included to: Inform the resident of facility's smoking policy and potential consequences of noncompliance, provide information and education in smoking cessation options, smoke in designated areas only, ensure staff maintained smoking materials and, supervised smoking. Record review of Safe Smoking Evaluations indicated Resident #9 was evaluated on 05/16/23. There were no other evaluations completed for 2023. During an observation on 9/18/23 at 11:20 a.m., Resident #9 was smoking in the designated smoking area with staff supervising. 2.Record review of a face sheet dated 09/20/23 indicated Resident #13 was a [AGE] year-old female admitted on [DATE] . Record review of an annual MDS dated [DATE] indicated Resident #13 had a BIMS score of 07 out of 15 indicating she had severely impaired cognition and was marked yes for current tobacco use. Record review of the care plan dated 10/04/22 indicated Resident #13 was a smoker with goals of will not suffer injury from unsafe smoking practices through the review date and intervention of Instruct resident about the facility policy on smoking: locations, times, safety concerns. Record review of Safe Smoking Evaluations indicated Resident #13 was evaluated 11/22. There were no other evaluations completed until 05/16/23. There were no other evaluations completed after May 2023. 675391 Page 6 of 24 675391 09/20/2023 Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 09/20/23 at 09:48 a.m. ADON D said nurses were to do a Safe Smoking assessment on admission, quarterly, or as needed per policy. Record review of a Smoking-Safety Screen policy and procedure revised 06/19 indicated: Policy: It is the policy of this facility that all residents who desire to smoke will be evaluated to determine their level of dependence and/or need for assistive devices in order to reduce the likelihood for risk of injury related to smoking and to honor resident smoking preferences while residing in the facility. Procedure: 1. Residents who desire to smoke will be assessed using a Smoking- Safety Screen to determine their level of independence while smoking and/or need for assistive devices. Smoking- Safety Screens will be conducted upon admission, quarterly, when a change of condition occurs and/or if there has been an incident of unsafe smoking observed or reported 3. Record review of a face sheet dated 09/20/23 indicated Resident #9 was a [AGE] year-old female admitted on [DATE] . Record review of an annual MDS dated [DATE] indicated Resident #9 had a BIMS score of 11 out of 15 indicating she had moderately impaired cognition, she required limited to extensive assistance with ADLs, and she had falls. Record review of the care plan dated 11/17/22 for Resident #9 indicated it was updated with the fall on 04/13/23 . Record review of Incident Reports Log for 04/23 indicated Resident #9 had a fall on 04/13/23. Record review of Fall Risk Assessments indicated Resident #9 was not evaluated after her fall on 04/13/23. 4.Record review of a face sheet dated 09/20/23 indicated Resident #18 was a [AGE] year-old female admitted on [DATE] . Record review of an annual MDS dated [DATE] indicated Resident #18 had a BIMS score of 12 out of 15 indicating she had moderately impaired cognition, she required extensive assistance with ADLs, and she had no falls. Record review of the care plan dated 11/17/22 for Resident #18 indicated it was updated with the fall on 04/06/23. Record review of Incident Reports Log for 04/23 through 09/23 indicated Resident #18 had a fall on 04/06/23. Record review of Fall Risk Assessments indicated Resident #18 was not evaluated after her fall on 04/06/23. 675391 Page 7 of 24 675391 09/20/2023 Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5.Record review of a face sheet dated 09/20/23 indicated Resident #29 was a [AGE] year-old male admitted on [DATE] . Record review of an annual MDS dated [DATE] indicated Resident #29 had a BIMS score of 03 out of 15 indicating he had severely impaired cognition, he required extensive assistance with ADLs, and he had no falls. Record review of the fall care plan dated 03/16/23 for Resident #29 indicated it was updated with the falls on 04/14/23 and 05/18/23. Record review of Incident Reports Log for 04/23 through 09/23 indicated Resident #29 had a fall on 06/25/23. Record review of Fall Risk Assessment indicated Resident #29 was not evaluated after his fall on 06/25/23. 6.Record review of a face sheet dated 09/20/23 indicated Resident #31 was a [AGE] year-old female admitted on [DATE]. Record review of an annual MDS dated [DATE] indicated Resident #31 had a BIMS score of 00 out of 15 indicating she had severely impaired cognition, she required extensive assistance with ADLs, and she had falls. Record review of the care plan dated 11/18/22 for Resident #31 indicated it was updated with the falls on 04/17/23, 04/30/23, 05/08/23, 05/11/23, 05/12/23, and 05/23/23. Record review of Incident Reports Log for 04/23 indicated Resident #31 had falls on 04/17/23 and 04/30/23. Record review of Incident Reports Log for 05/23 indicated Resident #31 had falls on 05/08/23, 05/11/23, 05/12/23, and 05/23/23. Record review of Incident Reports Log for 07/23 indicated Resident #31 had a fall on 07/19/23. Record review of Incident Reports Log for 08/23 indicated Resident #31 had falls on 08/03/23, 08/10/23, 08/13/23, and 08/15/23 Record review of Fall Risk Assessments indicated Resident #31 was not evaluated after her falls on 04/17/23, 04/30/23, 05/08/23, 05/11/23, 05/12/23, 05/23/23, 08/03/23, 08/10/23, 08/13/23, and 08/15/23. 7.Record review of a face sheet dated 09/20/23 indicated Resident #40 was an [AGE] year-old male admitted on [DATE] . Record review of an annual MDS dated [DATE] indicated Resident #40 had a BIMS score of 13 out of 15 indicating he was cognitively intact, he required limited assistance with ADLs, and he had no falls. Record review of the care plan dated 01/20/22 for Resident #40 indicated it was updated with the 675391 Page 8 of 24 675391 09/20/2023 Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656

F 0689 fall on 06/12/23. Level of Harm - Minimal harm or potential for actual harm Record review of Incident Reports Log for 04/23 through 09/23 indicated Resident #40 had a fall on 06/12/23. Residents Affected - Some Record review of Fall Risk Assessments indicated Resident #40 was not evaluated after his fall on 06/12/23. 8.Record review of a face sheet dated 09/20/23 indicated Resident #54 was a [AGE] year-old female admitted on [DATE]. Record review of an annual MDS dated [DATE] indicated Resident #54 had a BIMS score of 09 out of 15 indicating she had moderately impaired cognition, she required supervision with ADLs, and she had falls. Record review of the fall care plan dated 06/06/23 for Resident #54 indicated it was updated with the falls on 04/14/23 and 05/18/23. Record review of Incident Reports Log for 04/23 through 09/23 indicated Resident #54 was not evaluated after her falls on 05/13/23 and 06/15/23. Record review of Fall Risk Assessments indicated Resident #54 her falls on 05/13/23 and 06/15/23 . 9.Record review of a face sheet dated 09/20/23 indicated Resident #58 was an [AGE] year-old male admitted on [DATE] . Record review of an annual MDS dated [DATE] indicated Resident #58 had a BIMS score of 10 out of 15 indicating he had moderately impaired cognition, he required supervision with ADLs, and he had falls. Record review of the fall care plan dated 03/16/23 for Resident #58 indicated it was updated with the falls on 04/14/23 and 05/18/23. Record review of Incident Reports Log for 04/23 through 09/23 indicated Resident #58 had falls on 04/14/23 and 05/18/23. Record review of Fall Risk Assessments indicated Resident #40 was not evaluated after his falls on 04/14/23 and 05/18/23. During an interview on 09/20/23 at 09:48 a.m. ADON D said nurses were to do a Fall Risk Assessment admission, quarterly, after a fall, or as needed per policy. She said when a resident had a fall the charge nurse who was completing the assessment and Incident Report should initiate the Fall Risk Assessment for the IDT for follow-up. Record review of a Fall Management policy and procedure date 01/19 indicated: Policy: It is the policy of this facility to evaluate extent of injury after a fall, prevent complications 675391 Page 9 of 24 675391 09/20/2023 Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656

F 0689 and to provide emergency care. Each resident will be evaluated upon admission, quarterly, after Level of Harm - Minimal harm or potential for actual harm a fall, and as needed by a licensed nurse to evaluate his/her individual level of risk. The Interdisciplinary Team will review the Fall Risk Evaluation completed by the nursing department and Residents Affected - Some if appropriate, a fall prevention protocol will be initiated 675391 Page 10 of 24 675391 09/20/2023 Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 3 of 3 residents (Residents #14, #44, and #57) reviewed for enteral feeding. The facility failed to initiate dietician recommendations for Resident #14. LVN F force flushed water through Resident #44's G-tube that was clogged. LVN G failed to check Resident #57's G-tube placement by aspirating for residual feeding before enteral administration of medications. These failures could place residents receiving enteral nutrition and medications at increased risk of not receiving the proper nutrition, infection, and aspiration. Findings include: 1. Record review of Resident #14's face sheet indicated she was [AGE] years old and admitted on [DATE] with diagnosis of tracheostomy (surgical opening in the windpipe). Record review of Resident 14's physician orders dated September 2023 indicated NPO (Nothing by Mouth) and received Enteral Feeding-Order* Glucerna 1.5 at 55 ml/hr.x22hrs.free water at 35ml/hr. Record review of the MDS dated [DATE] indicated Resident #14 received gastric tube feedings over the last seven days while being a resident at the facility. Record review of the dietary recommendation for Resident #14 dated 09/07/23 indicated there was a dietary recommendation to change her gastric tube feeding to Glucerna 1.5 at 55 ml/hr.x22hrs.free water at 35ml/hr. Record review of care plan dated 04/14/23 indicated Resident #14 was at risk for aspiration, unplanned weight loss, dehydration and nutritional complication -Receiving Total nutrition/hydration via feeding tube Diagnosis of quadriplegia(unable to move all four limbs). During an observation on 09/18/23 at 9:20 a.m., Resident #14 feeding was Glucerna 1.2 running at 65 cc per pump at gastric feeding tube and water was at 75 cc. During an interview and observation on 9/18/23 at 10:20 a.m., LVN K said that they do not have Glucerna 1.5 and was not aware of the new order. She said as she looked at the physician order dated 09/15/23, this had not been started and she had initialed in error. She walked to the supply room and said there was no Glucerna 1.5. Record review of the MAR dated September 2023 indicated Resident #14 received a new order for Glucerna 1.5 at 55 ml/hr.x22hrs.free water at 35ml/hr. 675391 Page 11 of 24 675391 09/20/2023 Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #14's nurse notes in the electronic record indicated on 9/15/23 that ADON E had called the physician and family to notify of dietary recommendation. During an interview on 09/18/23 at 11:00 a.m., ADON E said she had worked on a dietary recommendation on Friday (09/15/23) for Resident #14 but had not verified the order with the physician and was waiting on their return call and the dietician recommendations must be approved before they are initiated. She said she had placed the order in the electronic record and should have waited until the physician approved and ordered the formula Glucerna 1.5. During an interview on 09/20/23 at 9:00 a.m., the interim DON said the facility had not received the recommendations for Resident #14 until 09/15/23 and should have received the recommendations after the dietician visited on 09/07/23. She said the recommendations should had been sent to the facility, approved by the physician, placed on the MAR, ordered the formula and started the new orders. She said the risk for the residents was not receiving the recommendations. The undated policy for dietary recommendations indicated the recommendations would be followed up by notifying the physician within 72 hours of the recommendations. 2. Record review of Resident #44's face sheet and physician orders dated September 2023 indicated she was [AGE] years old and admitted to the facility 01/19/20. Her diagnosis included dysphagia (difficulty or discomfort in swallowing) and aphasia (affects ability to communicate). Orders indicated she was NPO (nothing by mouth) and was to receive all feedings and medications via G-tube (a tube inserted through the stomach). Record review of care plan revised 0714/22 indicated Resident #44 required tube feeding via G-tube related to swallowing problem. Interventions included Report any tube dysfunction or malfunction. Record review of Resident #44's quarterly MDS dated [DATE] indicated she had severely impaired cognition, required extensive assistance with ADLs, and received nutrition via a feeding tube. Record review of Resident #44's MAR dated September 2023 indicated she was to receive all medications via G-tube. During an observation of medication pass on 09/19/23 beginning at 08:58 a.m., LVN F checked Resident #44's G-tube for placement by aspiration (pull back on the syringe plunger) and no residual was seen. She poured 20 ml of water into G-tube to flush tube and fluid would not go in. LVN F tried to milk the tubing and changed resident's position and water would still not flow in. LVN poured the water back into a cup. She then drew up 20 ml of water using the syringe and force flushed the water through the tube using the syringe plunger. She then finished giving the medications. Resident showed no reacation to G-tube being force flushed. During an interview on 09/20/23 at 08:00 a.m., LVN F said she normally did not force flush a G-tube unless it was stopped up. She said she had received training on administering G-tube medications and flushing G-tubes in LVN school. She said she also went through and orientation when she started work at the facility 2 years ago with a former unit manager. She said she did not know what the facility policy was on force flushing a G-tube. She said possible negative outcome of force flushing could be tube displacement. During an interview with ADON D and ADON E on 09/20/23 at 8:25 a.m., ADON D said G-tubes should 675391 Page 12 of 24 675391 09/20/2023 Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some never be force flushed because it could cause tube displacement. ADON E said it could also cause aspiration, harm to the tissue or leakage into the abdominal cavity. ADON D said skills check offs were done with LVNs yearly by the previous DON which included G-tube placement checks. She said the facility policy said G-tubes were never to be force flushed. During an interview on 09/20/23 at 8:25 a.m., the interim DON said G-tubes were never to be force flushed because it could cause tube displacement, leakage of fluid outside the stomach leading to infection, or aspiration. She said she and the ADONs were responsible for supervising nursing staff. 3. Record review of Resident #57's face sheet and physician orders dated September 2023 indicated he was [AGE] years old and admitted to the facility 06/08/23. His diagnosis included aphasia following nontraumatic intracranial hemorrhage (bleeding into the brain in the absence of trauma or surgery), tracheostomy (an incision into the windpipe made to relieve an obstruction to breathing) and gastrostomy (an opening into the stomach from the abdominal cavity for the introduction of food. Orders indicated he was NPO and was to receive all feedings and medications via G-tube. Record review of Resident #57's quarterly MDS dated [DATE] indicated he had severely impaired cognition and was totally dependent for all ADLs. He had diagnosis of aphasia and received nutrition via his G-tube. Record review of Resident #57's care plan revised 07/03/23 indicated he received total nutrition/hydration via G-tube. Interventions included check placement of G-tube prior to initiating feeding/flush. Record review of Resident #57's MAR dated September 2023 indicated he was to receive his medications via G-tube. During an observation and interview on 09/20/23 beginning at 07:50 a.m., LVN G had prepared the Resident's G-tube medications. LVN checked placement of G-tube by using her stethoscope and 10ml of air injected into the G-tube. She did not aspirate to check placement of G-tube. She then inserted the syringe into the G-tube and picked up medication for administration. Surveyor stopped LVN and asked if she usually checked placement only by auscultation (to listen). LVN said she usually auscultated and aspirated but yesterday the DON told her she only had to auscultate before medication administration. LVN then tried to aspirate fluid with no residual noted and administered medications. She said she had been trained to auscultate and aspirate to check G-tube placement before administering medications. During an interview on 09/20/23 at 8:15 a.m., ADON D said facility policy for checking G-tube placement was aspiration. She said not checking for placement could result in giving medications or fluid to a tube that was not in place in the stomach, damage to the stomach, aspiration, or infection. She said she had never done checks or observations of nurses checking G-tube placement. During an interview on 09/20/23 at 08:25 a.m., the interim DON said all G-tubes should be checked for placement by auscultation and aspiration to prevent administering fluids outside the stomach. She said she had instructed LVN G to auscultate and aspirate. She said she was unaware that facility policy indicated G-tubes should be checked by aspiration of stomach contents and auscultation was no longer recommended for checking placement. Facility policy titled Enteral Feedings revised January 2023 indicated in part . Auscultation is no 675391 Page 13 of 24 675391 09/20/2023 Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656

F 0693 Level of Harm - Minimal harm or potential for actual harm longer recommended for checking the placement of the feeding tube. Movement of air would likely be heard whether the tube was in the correct or incorrect location. Facility policy titled Enteral Tube Medication Administration revised August 2020 indicated in part Do not force flush the tube in an attempt to clear the tube. If the clog is persistent, contact the physician Residents Affected - Some Facility policy titled Enteral Feedings revised January 2023 indicated in part . Auscultation is no longer recommended for checking the placement of the feeding tube. Movement of air would likely be heard whether the tube was in the correct or incorrect location. 675391 Page 14 of 24 675391 09/20/2023 Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review the facility failed to ensure they had a full time DON and failed to ensure the had an RN for 8 consecutive hours 7 days a week for 6 of 6 months reviewed for RN coverage. Residents Affected - Many * The facility did not have a full-time DON between 9/02/23 and 9/18/23. * The facility did not have RN coverage for 8 consecutive hours on Saturday and Sunday. These failures could place residents at risk of lack of nursing oversight and a higher level of care. 1. During an interview upon entrance on 09/18/23 at 08:46 a.m. the ADM said she had no full time DON and will call to try and get interim back. During an interview on 09/19/23 at 10:35 a.m. the ADM said the previous DON's last day was 07/21/23. She said the Interim DON originally began on 07/24/23. She said the Interim DON was off on 07/25/25 but they did have RN coverage for the day. She said the interim DON contract ended on 09/01/23. She said she thought the Interim DON was going to stay until October 2nd. She said she renewed the contract for the Interim DON on Monday 09/18/23. During an interview on 09/20/23 at 08:20 a.m. the Interim DON said she worked as the Interim DON on 07/24/23 through 09/01/23. She said she came back and renewed the contract for the Interim DON position on Monday 09/18/23. She said she was not the Interim DON from 09/02/23 through 09/17/23. During an interview on 09/20/23 at 09:32 a.m. the HR said the previous DON last day worked was 07/21/23. She said they only had the Interim DON until 09/01/23. She said there was no DON or Interim DON from 09/02/23 through 09/18/23. 2. Record review of RN A's time sheets from 04/01/23 through 09/18/23 indicated the following: * RN A worked 05:45 p.m. until 12 midnight for 6.25 hours on 04/01/23, 04/15/23, 04/29/23, and 05/13/23. * RN A worked 12:01 a.m. until 06:15 a.m. then worked 05:45 p.m. until 12 midnight with a 11.5 hour gap (not consecutive hours) on 04/02/23, 04/16/23, 04/30/23, 05/14/23, 05/27/23, 05/28/23, 06/10/23, 06/11/23, 06/24/23, 06/25/23, 07/08/23, 07/09/23, 07/22/23, 07/23/23, 08/05/23, 08/06/23, 09/02/23, 09/03/23, 09/16/23, and 09/17/23. Record review of RN A and RN B time sheets indicated on 04/09/23 RN B worked 06:15 a.m. until 12:15 p.m. for 6.0 hours and RN A worked 05:45 p.m. until 12 midnight for 6.25 hours with a 5.5 hour gap (not consecutive hours) between the two RNs. Record review of RN B's time sheets from 04/01/23 through 09/18/23 indicated the following: * on (SA) 05/20/23 worked 06:15 a.m. until 02:00 p.m. for 7.75 hours; 675391 Page 15 of 24 675391 09/20/2023 Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656

F 0727 * on (SU) 05/21/23 worked 06:30 a.m. until 02:15 p.m. for 7.75 hours; Level of Harm - Minimal harm or potential for actual harm * on (SU) 06/04/23 worked 06:15 a.m. until 02:00 p.m. for 7.75 hours; * on (SA) 06/17/23 worked 06:30 a.m. until 02:30 p.m. for 7.50 hours; Residents Affected - Many * on (SA) 07/01/23 worked 06:30 a.m. until 02:15 p.m. for 7.75 hours; * on (SU) 07/02/23 worked 06:30 a.m. until 02:15 p.m. for 7.75 hours; * on (SA) 07/15/23 worked 07:00 a.m. until 12:30 p.m. for 5.25 hours; and * on (SU) 09/10/23 worked 06:00 a.m. until 01:45 p.m. for 7.75 hours. During an interview on 09/19/23 at 10:30 a.m. the administrator said she did not realize the RNs were not completing the 8-hour shift. She said ultimately it was corporate who hired new DONs. During an interview on 09/20/23 at 08:55 a.m. the HR said she was trying to find if there was any other information for the less than 8 consecutive hour RN time . 675391 Page 16 of 24 675391 09/20/2023 Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review, the facility failed to employ sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 1 of 1 facility kitchen. The facility failed to designate a person to serve as the Dietary Manager who met the required qualifications. The facility designated Dietary Manager did not have a Dietary Managers certification or any other qualifying credentials. This failure could place residents at risk for the spread of foodborne illness and residents not having their nutritional needs met. The findings include: Record review of the personnel file for the DM indicated documentation that she had completed the certified Dietary Manager course on 07/27/23 and she had not completed the final certification test or other qualifying credentials. She had a date of hire of 07/06/23. During an interview on 9/19/23 at 10:07 a.m., the DM said since she started the position of DM, she had completed the certified Dietary Manager course and had not taken the final certification test. She said she had a food handler certificate. During an interview on 9/19/23 at 10:30 a.m., the Administrator said the DM will take the test today for her certification of DM. She said the facility's procedure was to hire a Dietary Manager which would work on their Certified Dietary Manager credentials. The administrator said the Dietician was contracted and not full-time in the facility. During record review on 9/19/23 at 1:30 p.m., after surveyor intervention the DM and administrator presented a certificate indicating the DM passed the test on 09/19/23. Record review of the undated facility policy, titled Dietary Manager indicated . In keeping with our organization's goals, this position is responsible for overseeing the dietary and nutritional needs of all patients of the facility.Required Education and Experience . Maintain an active license as a certified dietary manager or certified food service manager . 675391 Page 17 of 24 675391 09/20/2023 Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review the facility failed to ensure the menu met the nutritional needs of residents in accordance with established national guidelines, be prepared in advance and was followed for two of three meals (lunch on 09/18/23 and breakfast on 09/19/23) reviewed for food and nutrition services. The facility failed to ensure the menu was followed for the lunch on 09/18/23 The facility failed to ensure the menu was followed for the breakfast meal on 09/19/23 These deficient practice could place residents at risk of dissatisfaction, poor intake, and/or weight loss. Findings include: During an observation on 09/18/23 at 12:30 p.m., a posted menu in the dining room indicated the lunch meal was Lunch: Slow-Cooked Beef Tips in Gravy, Steamed Rice, Seasoned Mixed Vegetables and Chocolate Chip Cookies. During observations on 09/18/23 at 12:35 p.m. in the dining room revealed the residents were served chocolate chip cookies with no chocolate chips. Some of the cookies were very brown and the residents were unable to eat them. During a confidential interview, they said the cookie was hard and were unable to take a bite of the cookie or cut it with a knife. During an interview on 09/18/23 at 12:45 p.m., the DM said chocolate chips were not in the budget and she did not report to administrator, she just forgot. The DM said if they were out of items or needed items, she should have reported to the Administrator and did not. During an observation on 09/19/23 at 7:45 a.m., a posted menu in the dining room indicated the breakfast meal was Breakfast: Choice of Juice, Choice of Hot or Cold Cereal, Garden Egg Bake, Hash Browns, Toast and 2% Milk. During an observation on 09/19/23 at 7:50 a.m., the garden egg bake served to the residents was yellow scrambled eggs and had no pieces of green peppers or red peppers. The grits were thin and contained clear liquid and when put on the spoon would just pour off the spoon when tilted. There were no hashbrowns and nothing was substituted for the hash browns. During an interview on 09/19/23 at 9:00 a.m., the DM said they did not have the red and green peppers and she was responsible for ordering or obtaining food items. She said, the cook and myself did not follow the menus or the recipes. The DM said she had ordered hash browns, but the supplier had not sent them or notified the facility. During a confidential on 09/19/23 at 10:00 a.m., they said the kitchen staff does not follow the menus and the kitchen was out of food items all the time. They said that is what they were told. 675391 Page 18 of 24 675391 09/20/2023 Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During confidential interviews on 09/20/23, they said, the grits were watery this morning and said the grits were always thin. During an interview on 09/20/23 at 10:55 a.m., hospitality aide J said she was in the dining room this morning and the grits were so watery the residents were not eating them and refused when offered substitute. She said she did not report it to the nurse however she will report it to the Administrator from now on. During an interview on 09/20/23 at 11:00 a.m., the Administrator said her expectation was for the dietary staff to follow the menus and the recipes. She said if the dietary staff had told her about the needed items, she would have obtained the items from the local grocery store. She said a complaint was filed related to the watery grits, and she was investigating why the grits were being watery. Record review of the facility's week at a glance menu, dated 09/18/23, indicated for Monday, 09/18/23 the following: lunch meal was Lunch: Slow-Cooked Beef Tips in Gravy, Steamed Rice, Seasoned Mixed Vegetables and Chocolate Chip Cookies. Record review of the facility's week at a glance menu, dated 09/19/23, indicated for Tuesday, 09/19/23 the following: breakfast meal was Breakfast: Choice of Juice, Choice of Hot or Cold Cereal, Garden Egg Bake, Hash Browns, Toast and 2% Milk. Record review of the undated recipe for Chocolate Chip Cookies indicated Margarine, Frozen scrambled eggs, Yellow cake mix package water and Chocolate Chips . Record review of the undated recipe for Garden Egg Bake indicated Frozen scramble eggs, 2% milk, Salt, Black pepper, chopped onion, diced green peppers, red peppers . Record review of the facility's policy, revised July 2019, and titled Menus indicated: Nutrition Services Policies and Procedures Menus will be planned to meet the nutritional needs and preferences of the patients/residents and are in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences. 1. Utilize a facility menu to best fit the preferences of the patients/residents. 2. Use the menus without modification the first time through the menu cycle. At the end of the first menu rotation, the Nutrition/ Culinary Services Director (NSD) may modify the menus to meet the preferences of the residents, substituting foods of similar nutrient value for those items that were replaced. The facility dietitian approves and signs all menus, diet modifications, and menu changes. 675391 Page 19 of 24 675391 09/20/2023 Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656

F 0805 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview and record review, the facility failed to provide food in a form designed to meet individual needs for reviewed for food form. Residents Affected - Some The facility failed to ensure the residents who required a pureed textured diet, received the appropriate food form to meet their needs on 9/19/23 for the noon meal. The pureed broccoli had small pieces and strings of the broccoli was not fully pureed and smooth consistency. This failure could place the residents at risk of aspiration and choking. Findings included: During an interview and observation on 09/19/23 at 11:30 a.m. [NAME] H said she was the person responsible for pureeing the food and had been trained on pureeing food on hire. She said the roasted broccoli takes longer to puree thoroughly as she placed the broccoli in the food processor. She placed a piece of bread into the processor and said this helps make broccoli smooth. During an observation of a test tray on 09/19/23 at 12:55 p.m., the pureed broccoli had small pieces and had stringy texture. The regional nurse tasted the pureed broccoli and said the food did have small pieces of food that had not been fully pureed and was not smooth to pudding consistency. She said the residents could possibly have difficulty swallowing. During an interview on 09/19/23 at 12:57 p.m., the DM declined to taste the pureed broccoli and said, the cook pureed for a long time and maybe we needed to substitute for the roasted broccoli for the pureed trays. During an interview on 9/19/23 at 12:59 p.m., the regional nurse tasted the pureed broccoli and said it was stingy with small pieces. She said it should be smooth like pudding. Record review of the diet roster dated 09/18/23 indicated 5 residents received a pureed diet. A reference obtained on internet on 09/21/23 at: https://iddsi.org/IDDSI/media/images/ConsumerHandoutsAdult/4_Pureed_Adults_consumer_handout_30Jan2019.pdf indicated Level 4 Pureed Food for Adults . level 4 - Pureed Food may be used if you are not able to bite or chew food or if your tongue control is reduced. Pureed foods only need the tongue to be able to move forward and back to bring the food to the back of the mouth for swallowing. It's important that puree foods are not too sticky because this can cause the food to stick to the cheeks, teeth, roof of the mouth or in the throat. Pureed foods are best eaten using a spoon. Examples of foods to AVOID: . broccoli . 675391 Page 20 of 24 675391 09/20/2023 Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the kitchen reviewed for dietary services. Residents Affected - Many The facility failed to prevent the following: Two of 4 freezers had 3-to-4-inch layer of buildup of ice. The juice dispenser nozzle (gun) had thick buildup of black and red substance on the inside of the nozzle. The deep fryer contained very dark grease with particles of food debris and had an odor. Food items were not properly labeled with product and expiration date in the refrigerator. The grates on the stove had buildup of black substance. These failures could place residents, who ate meals prepared in the kitchen, at risk for food borne illness. Findings included: During an observation and interview with the DM on 9/18/23 from 8:30 a.m. through 9:45 a.m. revealed: Two of the 4 freezers in the kitchen had a thick buildup (approximately 3-4 inches) of ice and frost along the inside walls of the freezers. The DM said the freezers needed to be defrosted and she was responsible for dethawing the freezers. The DM and the cook tried to remove the nozzle to view the inside of the juice machine dispenser nozzle (gun) The inside had a thick coating of dry black and red substance and the kitchen staff was unaware how to clean the head of the nozzle. The DM said she would have maintenance supervisor find out how to clean the nozzle. The refrigerator contained Three 10-ounce bowls of beans with no label of cook date or expiration date. A large container of beans and rice with no label of cook date or expiration date. Three pitchers of juice had no label with date placed in refrigerator. The DM said all food and juice must be labeled with a cook date or when it was placed in the refrigerator and when to discard items. The grease in the deep fryer was very dark and full of particles of food debris and had an odor., The DM said it had been over 2 weeks since the fryer had been cleaned and she was waiting on the grease to come in to clean the fryer. The DM said the deeper fryer was used on last Friday (09/15/23) to fry fish. During an interview on 09/20/23 at 9:30 a.m., the DM said all food items must be dated and kitchen 675391 Page 21 of 24 675391 09/20/2023 Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656

F 0812 must be kept clean to prevent food born illnesses and the cooks are responsible for dating items. Level of Harm - Minimal harm or potential for actual harm During an interview on 09/20/23 at 10:30 a.m., the Administrator said the expectations were for the kitchen to be cleaned per the cleaning schedule and deep fryer to be cleaned weekly and food stores with dates. Residents Affected - Many Reference obtained on internet on 9/22/23., https://www.fda.gov/media/110822/download . (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; . Reference obtained on internet on 9/22/23., https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basics/leftovers-and-food-safety . Store Leftovers Safely .Safe handling of leftovers is very important to reducing foodborne illness. Follow the USDA Food Safety and Inspection Service's recommendations for handling leftovers safely.Leftovers can be kept in the refrigerator for 3 to 4 days or frozen for 3 to 4 months . The Fryer Policy dated 12/31/19 indicated The facility will maintain deep fryers in a clean and sanitary condition. Procedure: 1. A NFS staff member is to clean the deep fryer weekly per posted cleaning schedule. The undated Dietary Cleaning Schedule indicated . Tuesday AM aide -Clean juice machine on top and on the side and clean the juice gun. Friday-PM cook Clean stove . 675391 Page 22 of 24 675391 09/20/2023 Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656

F 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and record review the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. The facility failed to submit direct care staffing information on the schedule specified by CMS (Centers for Medicare and Medicaid Services), but no less frequently than quarterly for 1 of 3 quarters reviewed for payroll data information. *The facility failed to submit staffing information to CMS for the 3rd quarter of the fiscal year 2023. This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings included: Record Review of the facility's Civil Rights form (3761) dated 09/18/23 indicated the following: 5 RN's 14 LVNs 19 Direct Care Staff 8 Dietary 6 Housekeeping & Laundry 20 All Others Record review of the CMS PBJ Staffing Data Report (payroll-based staffing), CASPER Report (Certification and Survey Provider Enhanced Report)1705 D FY Quarter 3 2023 (April 1- June 30), dated 09/14/2023, indicated the following entry: Failed to Submit Data for the Quarter Triggered .Triggered=No Data Submitted for the Quarter. Record review of time sheets from 04/01/23 through 09/18/23 indicated RN hours daily had issues with less than 8 hours per day and there were adequate number of LVN hours, CNA hours, CMA hours daily. During an interview on 09/19/23 at 11:53 a.m., the ADM said their staffing was being submitted quarterly by either the facility HR staff or the corporate HR department. She said the facility had received no notification of any concerns or that the PBJ staffing information had not been sent. During an interview on 09/19/23 at 2:22 p.m., HR said the corporate HR department was responsible for submission of the staffing data to CMS every quarter (every three months). She said she contacted the corporate HR department and was told the PBJ report was submitted a day late. A policy regarding the PBJ reporting was requested. 675391 Page 23 of 24 675391 09/20/2023 Paradigm at the Pines 705 Hwy 418 W Silsbee, TX 77656

F 0851 A policy regarding the PBJ reporting was not provided prior to exit. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 675391 Page 24 of 24