Health inspection·June 27, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many were responsible and should have ensured opened food items in the freezer and refrigerator were labeled, dated and sealed. She further said the food that was opened was a week old and would have been delivered a week ago. She said the facility received a delivery every Tuesday and the open food would have been from the week before. She said she needed to review the facility policy on food storage. The Dietary Manager said if the food item did not have an expiration date, then the food was thrown out in three days. She said the half an onion did not need an open date or use by date. The Dietary Manager said, I [onion]is a visual thing and you can see when mold is on it. She said, For perishables like onions we do not have to put a date on them. She said she put the current date (6/27/24) on the frozen corn and pizzas because they came last week and she knew the food was not bad. She said she knew the food was good because, any food opened in the refrigerator or freezer came the week before. She said residents were at risk if they ate food that was ate past the foods' use by date. Interview on 6/27/2024 at 11:21 a.m., the Regional Dietician said dairy items (like the open shredded cheese) did not need an open date and the expirations date was what the staff used to determine when the dairy should be discarded. She said she was not at the facility on a normal basis so she could not answer questions about how staff labeled, sealed and dated open food items. She said the Dietary Manager would have to answer food storage questions. 2. Observation on 6/27/2024 at 12:03 p.m. revealed [NAME] A had gloves on at the steam table. [NAME] A continued to where the same gloves as she held a binder and a pen while she documented holding temperatures. [NAME] A did not change gloves and plated food. [NAME] A with the same gloves, ran her left hand down the left side of the plate warmer. She came back to the steam table, picked up three separate pieces of sliced bread and placed them on plates that were placed on a hall cart. Interview on 6/27/2024 at 12:17 p.m., the Dietary Manager said [NAME] A should not have touched multiple unclean surfaces with gloves and pick up bread that was placed on a resident plates. The Dietary Manager said [NAME] A should have changed gloves before she picked up the bread. The Dietary Manager said cross contamination could have occurred between the unclean gloves and bread. She said the residents were at risk and could have become sick from cross contamination. Interview on 6/27/2024 at 2:17 p.m., [NAME] A (with Spanish interpreter on phone) said opened food items should be dated and labeled. She said she and the Dietary Manager were responsible and ensured open food items were dated and labeled in the freezer and refrigerator. [NAME] A said she forgot to label the frozen corn in the freezer. She said she had a food handlers' certificate, which taught her to date and label food. She said food was dated and labeled to ensure residents did not get sick from outdated food served. She said she wore gloves at the steam table because she wanted to protect her hand from sauces and not to have her bare hands on the resident plates. She said she forgot to change gloves when she wrote down the food temperatures before starting food services. She said she picked up the bread with the same gloves she used when she handled the food temperature binder and pen. She said she was trained on hand hygiene but did not remember the date. She said bacteria could be transferred when uncleaned gloves were used. Record review of the facility's policy Employee Sanitation (Approved date October 1, 2018), reflected the following in part: Policy: The Nutrition & Foodservice employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675612 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675612 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Westbury 5201 S Willow Dr Houston, TX 77035 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 5. Hand washing Level of Harm - Minimal harm or potential for actual harm a. Employees must wash their hands and exposed portions of their arms at designated hand washing facilities at the following times: Residents Affected - Many . iv. Immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles . v. During food preparation, as often as necessary to remove soil and contamination and prevent cross contamination when changing task . 6. Use of Gloves a. Gloves are not a substitute for thorough and frequent hand washing. When using gloves, always wash hands before touching or putting on new gloves . d. Change gloves: i. Between each food preparation task . ii. After touching items, utensils or equipment not related to task . iv. When leaving food preparation area for any reason . Record review of the facility's dietary in-service Handwashing, dated 1/6/2024, reflected the following: .Summary of training session: Proper handwashing through out shift, much was hand after each task. Record review of the facility's dietary in-service Labeling & Dating, dated 12/12/2023, reflected the following: .All incoming grocery should always have a receive date. Any open packets should have an open date and remain in its original packets. Any stored food mush be in container stored w/ date & 3 day discard date. Record review of Federal Drug Administration Food Code 2022 reflected [(C) PACKAGED FOOD shall be labeled as specified in LAW, including 21 Code of Regulation 101 FOOD Labeling, 9 Code of Regulation 317 Labeling, Marking Devices, and Containers, and 9 Code of Regulation 381 Subpart N Labeling and Containers, and as specified under § 3-202.18. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675612 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675612 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Westbury 5201 S Willow Dr Houston, TX 77035 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 7 staff (CNA A) reviewed for infection control. Residents Affected - Few CNA A failed to perform hand hygiene appropriately while she retrieved ice from the communal ice chest for a resident when she touched high touch areas including the resident door handle, bathroom door handle, resident cup and ice chest lid. This failure could place residents at risk for infection. The findings include: Observation on 6/27/2024 at 10:17 a.m. revealed CNA A responded to a resident who requested ice. CNA A did not wash or sanitize her hands before or after she walked into the room. CNA A knocked on the resident's door, took the cup from the resident, opened the door to the bathroom, poured the residual water that was in the cup. CNA A left out of the resident's room and walked to the to the ice chest located in the nurses' station/common area. CNA A picked up the ice scoop, dipped it in to the ice chest and poured the ice into the resident's cup. CNA A went back into the resident's room and handed the cup to the resident. CNA A did not wash or sanitize her hands after she provided the resident with the ice. Interview on 6/27/2024 at 10:19 a.m., CNA A said she responded to a resident who wanted ice. She said she took the cup from the resident, poured out left over water and scooped ice out of the ice chest. CNA A said she did not sanitize or wash her hands prior to getting the ice. She said she said she forgot. CNA A said she should have sanitized or washed or hands to prevent cross contamination. She said she could have spread germs to the residents. She said she had in-services on hand hygiene and was aware of using hand hygiene before providing care to residents. Interview on 6/27/2024 at 1:48 p.m. with the ADMIN revealed it was the facility policy for staff to wash their hands before they provided any type of care for the residents. He said a staff should have washed their hands before they scooped ice out of the ice chest. The ADMIN said the staff could have contaminated the ice with bacteria and risked exposing the residents to infection. He said all staff were responsible and should use proper hand hygiene. Interview on 6/27/2024 at 3:08 p.m., the DON said staff should sanitize their hands prior to touching a resident's cups and should use a napkin to pick it up. She said the staff's hands should be sanitized or washed prior to using the scooper and reaching into the ice chest to get the ice. She said staff were trained to use proper hand hygiene, so they did not cross contaminate or introduce germs that could place the residents at risk. Record review of the facility policy Nursing Policies and Procedures (revised June 2019) reflected the following in part: Subject: Hand Hygiene Policy: It is the policy of this facility that proper hand hygiene/hand washing technique will be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675612 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675612 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Westbury 5201 S Willow Dr Houston, TX 77035 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few accomplished at all times that handwashing is indicated. Hand Hygiene/Hand washing is the most important component for preventing the spread of infection . Definition of Terms: Hand hygiene. A general term that applies to either hand washing, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis . PROCEDURES: 1. Hand hygiene/hand washing is done: Before: A. Before patient/resident contact. B. Before eating or handling food . After: .B. After patient/resident contact. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675612 If continuation sheet Page 5 of 5