Inspection·October 2, 2024

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of physician's orders dated 10/02/24 indicated Resident #54 was prescribed apixaban 5 mg two times a day for heart failure (the heart does not pump blood as well as it should) with a start date of 06/13/24. Record review of Resident #54's September 2024 MAR indicated she received apixaban 5 mg two times a day for heart failure with a start date of 06/13/24. Record review of the most recent quarterly MDS assessment dated [DATE] indicated Resident #54 had a BIMS score of 5 indicating severely impaired of cognition but did not indicate that she received an anticoagulant medication during the last 7 days. Record review of Resident #54's care plan revised 07/03/24 indicated Resident #54 received an anticoagulant medication for heart failure. During an observation and interview on 09/30/24 at 10:00 a.m., Resident #54 was sitting in a wheelchair with no observed bruising. Resident #54 said she received an anticoagulant medication but was unsure which one. During an interview on 10/02/24 at 09:47 a.m., the MDS nurse said she was responsible for all MDSs in the facility. She said she was educated on completion of MDSs for accuracy. She said Resident #5's and #54's MDSs were not coded for receiving an anticoagulant medication and should have been. The MDS nurse said she had no back up to double check her MDSs for accuracy, but she could call the Regional Reimbursement Director for questions. She said Resident #5's and #54's MDSs not coded for received anticoagulant medication were overlooked. She said the risk of the MDSs not being accurately coded was not following policy, an inaccuracy that she would correct. The MDS nurse said the nurses had documented monitoring for side effects for the residents and were aware of the anticoagulant medication they received. During an interview on 10/02/24 at 9:59 a.m., the Regional Reimbursement Director said the MDS Nurse was responsible for all MDSs in the facility. She said she could fill in for the MDS nurse if needed but she did not monitor all MDSs for accuracy. She said she did occasional reviews for accuracy when needed and the MDS Nurse could call for questions or advice. The Regional Reimbursement Director said the MDSs not captured for the received anticoagulant medication were overlooked. She said the MDS Nurse was educated on MDS completeness and accuracy. She said a residents' MDSs not captured for receiving an anticoagulant did not increase or decrease money. She said the risk of an MDS not captured for received anticoagulant medication was an inaccuracy of coding that could be modified and corrected. The Regional Reimbursement Director said since the nurses had monitored the anticoagulant medication for side effects and the anticoagulant was care planned it was no risk to the resident. During an interview on 10/02/24 at 10:09 a.m., the DON said the MDS Nurse was responsible for all MDSs in the facility and was educated on accuracy and completeness of MDSs. She said Resident #5's and #54's anticoagulants should have been captured on the MDSs but were overlooked. The DON said the Regional Reimbursement Director was a backup, but she was unaware the Regional Reimbursement Director was not double checking MDSs for accuracy. The DON said she would start double checking the MDSs for accuracy and completeness. She said the risk of an MDS not captured when the resident received an anticoagulant was possible side effects not monitored. The DON said her expectation was all MDSs be completed and thorough. During an interview on 10/02/24 at 10:20 a.m., the Administrator said the MDS Nurse was responsible (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675391 If continuation sheet Page 2 of 13 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 10/02/2024 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for all MDSs in the facility and had received education on completion of MDSs. He said he was unaware the Regional Reimbursement Director did not check the MDSs for accuracy so the DON would start double checking them for accuracy. The Administrator said the resident risk of an MDS not including anticoagulant medication the resident received was the resident may not receive services required. He said his expectation was 100 percent compliance going forward with everything documented on the MDS and individualized to the resident. Record review of the facility policy revised June 2019, titled, Subject: Minimum Data Set indicated, .An MDS, which is a comprehensive, accurate, standardized reproducible assessment will be completed for each resident, using the RAI process. Record review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2023 indicated, . N0415: High-Risk Drug Classes: Use and Indication 1. Is taking: Check if the resident is taking any medication by pharmacological classification, not how it is used during the last 7 days or since admission/ reentry or reentry if less than 7 days. N0415E1. Anticoagulant (eg., warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at anytime during the 7- day look back period.Coding Tips and Special Populations . Do not code antiplatelet medication such as aspirin/ extended release, dipyridamole, or clopidogrel as N0415 E, Anticoagulant. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675391 If continuation sheet Page 3 of 13 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 10/02/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 17 residents. (Resident #5) The facility failed to develop a care plan for Resident #5's anticoagulant (blood thinner) medication, Eliquis. This failure could place the residents at risk of not receiving care and services to maintain their highest level of well-being. Findings included: Record review of a face sheet dated 10/02/24 indicated Resident #5 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included embolism (sudden blocking of an artery) and thrombosis (formation of a blood clot inside a blood vessel) of her left lower extremity on 02/20/24. Record review of physician's orders dated 10/02/24 indicated Resident #5 was prescribed Eliquis 2.5 mg two times a day with a start date of 02/08/24. Record review of Resident #5's September 2024 MAR indicated she received Eliquis 2.5 mg two times a day for venous thrombosis with a start date of 02/08/24. Record review of the most recent annual MDS assessment date 07/17/24 indicated Resident #5 had a BIMS score of 14 indicating cognitively intact but did not indicate that she received an anticoagulant medication during the last 7 days. Record review of Resident #5's care plans revised 07/29/24 did not indicate Resident #5 received the anticoagulant medication. During an observation 09/30/24 at 11:00 a.m., Resident #5 was lying in bed with no observed bruising. She said she received an anticoagulant medication but was unsure which one. During an interview on 10/02/24 at 09:46 a.m., the MDS Nurse said she was responsible for all care plans in the facility. She said she was educated on completion of care plans and accuracy. She said Resident #5 was not care planned for the anticoagulant, Eliquis she received and should have been. The MDS nurse said she would care plan it now. The MDS nurse said she had no back up to double check her care plans for accuracy, but she could call the Regional Reimbursement Director for questions. She said the care plan was overlooked. The MDS nurse said the risk of Resident #5's anticoagulant not being care planned was not following policy. She said the nurses documented monitoring for side effects for Resident #5's anticoagulant. During an interview on 10/02/24 at 9:57 a.m., Regional Reimbursement Director said the MDS nurse was responsible for all care plans in the facility. She said she could fill in for the MDS nurse if needed but she did not monitor care plans for accuracy. The Regional Reimbursement Director said the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675391 If continuation sheet Page 4 of 13 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 10/02/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few MDS nurse was educated on care plans completeness and accuracy and could call her for questions or advice. The Regional Reimbursement Director said the risk of Resident #5's anticoagulant overlooked care planned was not following policy due to Resident #5's MAR indicated the nurses monitored Resident #5 for side effects. During an interview on 10/02/24 at 10:07 a.m., the DON said the MDS Nurse was responsible for care plans in the facility and was educated on accuracy and completeness of care plans. She said Resident #5's anticoagulant care plan was overlooked and should have been care planned. The DON said the Regional Reimbursement Director was a backup for the MDS nurse that she was unaware was not double-checking care plans for accuracy. The DON said she would start double-checking care plans for accuracy and completeness. She said the resident risk of receiving an anticoagulant and it not being care planned was possible side effects not being monitored. The DON said her expectation was anticoagulants were care planned on all residents that received anticoagulants. During an interview on 10/02/24 at 10:15 a.m., the Administrator said the MDS Nurse was responsible for care plans in the facility and was educated on accuracy and completion of care plans. He said he was unaware the Regional Reimbursement Director did not check the care plans for accuracy and the DON would now start double checking them. The Administrator said Resident #5's care plan was overlooked. He said the resident risk of a care plan not including anticoagulant medication the resident had received was the resident may not receive services required. He said his expectation was 100 percent compliance going forward with everything care planned and individualized to each resident. Record review of a facility policy titled, Nursing Policies and Procedures revised 06/2019 indicated: .Subject: CARE PLANNING . It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675391 If continuation sheet Page 5 of 13 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 10/02/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) in 1 of 3 medication carts reviewed (Hall B and right side of Hall C Nurse medication cart) in that: An insulin pen of Insulin Glargine yfgn (used to lower blood sugar) with an open date of 08/03/24, had been expired for 60 days and not removed from use. This failure could place residents at risk for accidents, hazards, and not receiving therapeutic effects of medication. The findings included: Record review of Resident #26's face sheet dated 10/02/24 indicated an [AGE] year-old male admitted [DATE] with diagnoses included: end stage renal disease (disease in which the kidneys lose the ability to remove waste and balance fluids) and type 2 diabetes mellitus (trouble controlling blood sugar). Record review of Resident #26's quarterly MDS assessment with an ARD of 07/16/24 indicated the resident had a BIMS score of 3 indicating the resident was severely impaired of cognition. The assessment indicated he was diagnosed with renal failure and diabetes mellitus and received insulin injections 7 of the last 7 days. Record review of Resident #26's care plan with a target date of 10/17/24 indicated he had diabetes and received insulin with an intervention to give as prescribed by the physician and monitor for side effects and effectiveness. Record review of Resident #26's physician's order, dated 06/26/24, indicated he was prescribed Insulin Glargine subcutaneous 100 unit/ml inject 15 units two times a day for type 2 diabetes mellitus, may hold if BS less than 100 with a start date of 06/26/24. During an observation and interview on 10/02/24 at 12:30 p.m., during a review of Hall B and the right side of Hall C Nurse's medication cart with LVN A, there was one opened insulin pen labeled Insulin Glargin yfgn 100 U/ml with an attached sticker labeled with Resident #26's name and dated with an open date of 08/03/24. LVN A said she was responsible for ensuring insulin, on her medication cart, in use beyond the recommended time frame of use after the opened date was removed. She said she checked her cart daily for expired medication and whenever she gave medication. She said Resident #26's insulin should have been removed 28 days after the open date and said it was overlooked. She said Resident #26 received insulin after the 28 days after the open date. She said the pharmacy consultant and DON double checked carts for expired medications and ensured insulin in use beyond the recommended time frame of use after opened date on medication carts were removed. LVN A said she was in-serviced to double check carts for expired medications and to ensure insulin in use beyond the recommended time frame of use after opened date on medication carts were removed. She said the risk to residents was insulin may not be as effective. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675391 If continuation sheet Page 6 of 13 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 10/02/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/02/24 at 02:40 p.m., the DON said the nurses were responsible for their medication carts, checked daily for expired medication and to ensure insulin in use beyond the recommended time frame of use after the open date on the medication carts was removed. The DON said the pharmacy consultant checked the medication carts monthly. She said she and the ADON did surprise checks quarterly. She said the nurses were in-serviced on removal of expired medication and to ensuring insulin in use beyond the recommended time frame of use after the open date on the medication carts was removed. She said Resident #26's insulin was overlooked. She said the resident risk was the insulin was possibly not as effective. The DON said her expectation was all expired medications removed and insulins removed on the recommend time frame after the open date. During an interview on 10/02/24 at 02:45 p.m., the ADON said the nurses were responsible to check their medication carts daily for expired medication and to ensure insulin in use beyond the recommended time frame of use after the open date on medication carts were removed. The ADON said the pharmacy consultant checked the medication carts monthly and herself and the DON did surprise checks quarterly. She said her last surprise check was in August 2024. The ADON said the nurses were in-serviced on removal of expired medication and to ensure insulin in use beyond the recommended time frame of use after opened date on the medication carts was removed. She said Resident #26's insulin was overlooked. The ADON said the risk to the resident was the insulin was possibly not as effective. During an interview on 10/02/24 at 3:00 p.m., the Administrator said the nurses were responsible to ensure all expired medication was removed from their medication carts and were required to check the medication carts daily. He said the DON and ADON did surprise checks quarterly of the medication carts and the staff were educated on removing expired medication off their medication carts. The Administrator said the risk to the resident was the insulin was possibly not as effective in insulin pens in use beyond the recommended time frame of use after the pen was opened. He said his expectation was the medication carts be checked daily for any expired medication. Record review of a facility policy titled, Facility Guide Insulin Reference Guide updated February 2024, indicated, . Insulin Glargine (yfgn) U-100 Pen . in-use storage . room temperature for up to 28 days . Record review of a facility policy titled, Nursing Policies and Procedures indicated, Subject: Medication Administration and Management .19. Outdated medication is destroyed or returned to the pharmacy according to applicable state rules and regulations and a new supply obtained when necessary. check both the enter date and expiration date on the vial Record review of a web site titled, INSULIN GLARGINE- insulin glargine-yfgn injection, solution Accessed on 10/03/24, indicated, .Insulin Glargine -yfgn is a long-acting human insulin .Only use your pen for up to 28 days after its first use. Throw away the Insulin Glargine-yfgn pen you are using after 28 days, even if it still has insulin left in it FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675391 If continuation sheet Page 7 of 13 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 10/02/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm 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 was followed for 1 of 3 meals reviewed for menus and nutritional adequacy. (Lunch meal 10/01/24) Residents Affected - Few The facility did not ensure the recipes were followed for the chicken wrap and potato salad served for lunch on 10/01/24. This failure could place residents at risk of not having their nutritional needs met. Findings included: During an observation and interview on 10/01/24 at 1:14 p.m., the test tray contained a chicken ranch wrap, potato salad and pear crisp with topping. The chicken wrap was not wrapped and appeared to be a taco. The meat in the tortilla was breaded and appeared soggy, lettuce appeared fresh, tomatoes appeared canned, with ranch dressing. The meat did not taste like chicken, and it was wet, soggy, and jelly like. The inside of the patties tasted burnt and appeared grey in color. The potato salad had a strong unsavory flavor of garlic. The DM said he did not taste the food when preparing it and he did not follow the recipes. He refused to taste the food because he said he did not eat those foods. Record review of the recipe for Chicken Ranch Wrap indicated: Ingredients Ranch dressing Romaine Lettuce heads Fresh tomatoes American cheese slices Thawed Pulled/Diced Chicken Tortilla Record review of the recipe for Potato Salad indicated: Ingredients Diced potatoes Hard boiled eggs Pickle relish Mustard (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675391 If continuation sheet Page 8 of 13 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 10/02/2024 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 0803 Salt Level of Harm - Minimal harm or potential for actual harm Mayonnaise salad dressing Paprika Residents Affected - Few During an interview on 10/01/24 at 2:10 p.m., the DM said when making the chicken wraps, he used breaded chicken patties because he did not receive chicken in his delivery yesterday. He said he omitted the American cheese from the wraps and substituted fresh tomatoes with canned diced tomatoes. He said when making the potato salad he omitted the hard-boiled eggs and pickle relish and added garlic which was not in the recipe. He said not following the recipes could result in residents not receiving the dietician approved recipes, decrease the nutritional value of the foods, and alter the taste of the food. During an interview on 10/02/24 at 3:45 p.m., the Administrator said his expectations were for the menus and the recipes to be followed and if they were not followed, it could cause the residents to not receive a nutritionally balanced diet. He said if foods were not received as ordered they could be purchased with the company credit card and the DM should have reported not receiving all ordered foods required for the recipes to him so the food could be purchased. Record review of a Food Preparation policy revised 0/2019 indicated: Policy- Food is to be prepared by methods that conserve nutritive value, flavor, and appearance. Procedure- . 3. Use the Culinary Recipe manual with standardized, yield -adjusted recipes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675391 If continuation sheet Page 9 of 13 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 10/02/2024 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared by methods that conserve nutritive value, flavor, and appearance and were palatable, attractive, and at a safe and appetizing temperature for 1 of 1 kitchen reviewed for food and nutrition services. Residents Affected - Some The facility did not ensure the chicken wrap and potato salad served for lunch on 10/01/24 were palatable. These failures could place the residents at risk of a decline in their satisfaction and weight loss. Findings included: During confidential interviews on initial rounds on 9/30/24 from 9:38 a.m. to 11:00 a.m., the residents complained about the food tasting bad and not being edible at times. During an observation and interview on 10/01/24 at 1:14 p.m., the test tray contained a chicken ranch wrap, potato salad and pear crisp with topping. The chicken wrap was not wrapped and appeared to be a taco. The meat in the tortilla was breaded and appeared soggy, lettuce appeared fresh, tomatoes appeared canned, with ranch dressing. The meat did not taste like chicken, and it was wet, soggy, and jelly like. The inside of the patties tasted burnt and appeared grey in color. The potato salad had a strong unsavory flavor of garlic. The DM said he did not taste the food when preparing it and he did not follow the recipes. He refused to taste the food because he said he did not eat those foods. The Dietician said the food tasted fine, but the recipes should have been followed. The Administrator said the food tasted off and were not pleasing. During an interview on 10/01/24 at 2:10 p.m., the DM said when making the chicken wraps, he used breaded chicken patties because he did not receive chicken in his delivery yesterday. He said he omitted the American cheese from the wraps and substituted fresh tomatoes with canned diced tomatoes. He said when making the potato salad he omitted the hard-boiled eggs and pickle relish and added garlic which was not in the recipe. He said not following the recipes could result in residents not receiving the dietician approved recipes, decrease the nutritional value of the foods, and alter the taste of the food. During an interview on 10/01/24 at 2:20 p.m., Resident #48 said he did not eat lunch today because the chicken wrap was not a wrap and it tasted bad. He said the potato salad did not taste like potato salad. During an interview on 10/01/24 2:22 p.m., Resident #28 said lunch was terrible today. She said she didn't know what that was in the wrap, but it wasn't chicken. She said the potato salad did not taste like any potato salad she had ever tasted, and she couldn't eat it. During an interview on 10/01/24 at 2:24 p.m., Resident #51 said the chicken in the wrap was overcooked and soggy and tasted bad. He said he could not eat the potato salad because it tasted bad. During an interview on 10/02/24 at 3:45 p.m., the Administrator said his expectations were for the menus and the recipes to be followed and if they were not followed, it could cause the residents to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675391 If continuation sheet Page 10 of 13 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 10/02/2024 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete not receive a nutritionally balanced diet. He said if foods were not received as ordered they could be purchased with the company credit card and the DM should have reported not receiving all ordered foods required for the recipes to him so the food could be purchased. Record review of a Food Preparation policy revised 0/2019 indicated: Policy- Food is to be prepared by methods that conserve nutritive value, flavor, and appearance . Event ID: Facility ID: 675391 If continuation sheet Page 11 of 13 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 10/02/2024 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 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 for 1 of 1 kitchen reviewed for dietary services. Residents Affected - Some The facility failed to ensure food items were properly labeled with product and expiration date in the freezers. The facility failed to properly close items stored in the freezers. 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 Dietary Manager on 09/30/2024 at 8:52 a.m. the following were observed: -Freezer #1 contained: A large, opened bag of okra that was not labeled or dated. An opened sleeve of waffles that was not labeled or dated. A large, opened bag of corn that was not labeled or dated. An opened bag of squash that was not labeled or dated and had not been properly closed and was exposed to air. Pieces of frozen squash were scattered throughout the freezer. -Freezer #2 contained: An open bag of okra that was not labeled or dated and had not been properly closed and okra was exposed to air. An open bag of riblets that was not labeled or dated and had not been properly closed and riblets were exposed to air. The Dietary Manager said all opened foods in the freezer should be labeled with the date opened and closed properly to prevent freezer burn of the food, cross contamination, and serving expired food to residents. He removed all unlabeled foods from the freezers and threw them away. During an interview on 10/02/24 at 3:45 p.m., the Administrator said he was the supervisor of the Dietary Manager. He said he expected for all foods in the kitchen to be stored properly including labeling and dating. He said food not being labeled and dated and stored properly could result in expired foods being served to residents. Record review of a facility policy titled Food Storage revised June 1, 2019, indicated . Store frozen foods in moisture-proof wrap or containers that are labeled and dated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675391 If continuation sheet Page 12 of 13 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 10/02/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the 2022 Food Code dated 01/18/23 indicated 3-305.11 Food shall be protected from contamination by storing the food: . (2) Where it is not exposed to splash, dust, or other contamination.3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date. Date marking is the mechanism by which the Food Code requires active managerial control of the temperature and time combinations for cold holding. Industry must implement a system of identifying the date or day by which the food must be consumed, sold, or discarded. Date marking requirements apply to containers of processed food that have been opened and to food prepared by a food establishment, in both cases if held for more than 24 hours, and while the food is under the control of the food establishment. This provision applies to both bulk and display containers. It is not the intent of the Food Code to require date marking on the labels of consumer size packages. A date marking system may be used which places information on the food, such as on an overwrap or on the food container, which identifies the first day of preparation, or alternatively, may identify the last day that the food may be sold or consumed on the premises. A date marking system may use calendar dates, days of the week, color-coded marks, or other effective means, provided the system is disclosed to the Regulatory Authority upon request, during inspections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675391 If continuation sheet Page 13 of 13