Health inspection·July 3, 2024

F 0584 Record review of Resident #2's 48 hour48-hour baseline care had not been completed. Level of Harm - Minimal harm or potential for actual harm Observation on 7/3/2024 at 11:13 a.m. of Resident #1 and Resident #2's and bathroom revealed: Residents Affected - Few Bathroom tile cracks: There were multiple hairline cracks in various length (slightly larger than the thickness of pencil lead). The first crack was approximately 12 inches long, the second crack was approximately 3.5 inches long. There was a 3 inch by 8.5-inch section of two tiles (side by side) that had missing and loose chipped tile. One tile at the entry of the bathroom door was not level to the other tile around it. Bathroom doorknob: The doorknob was not secure to the door and wobbled in each direction when grabbed. Resident #1's mat had multiple black spots that were gummy in texture. Room - Floor had multiple paper wrappers. When Surveyor walked on the floor, the shoes could be heard sticking to the floor with every step. Room Blinds - Blinds across from Resident 2's bed was bent. Interview on 7/3/2024 at 11:15 a.m., with Resident #1 and their family member revealed Resident #1 said she was not happy about how her room looked. Resident #1 said she did not like how the bathrooms floors were not in good repair and were dirty. Resident #1 said she noticed her bent blinds. The family member said the trash on the floor had been on the floor multiple consecutive days. The family member said the stained rim around the bottom of the toilet was not acceptable. Interview and observation on 7/3/2024 at 1:15 p.m., the ADON said Resident #1 and Resident #2's room should be clean. She said the bathroom floor and toilet needed to be cleaned. She Resident #1's mat should be cleaned or changed out and the trash on the floor needed to be picked up. She said the chipped and loose towel should be fixed because it posed a trip hazard for residents. She said housekeeping was responsible for cleaning the rooms and if repairs were needed then the request should be placed in the maintenance log at the nurse's station. Interview on 7/3/2024 at 1:30 p.m. with HK A, she said she had not cleaned Resident #1 and Resident #2's room yet. She said she was not aware of the broken tile and dirt around the bottom of the toilet. She said the room should have been mopped daily and she was not able to explain why the floor was sticky. She said resident rooms should be cleaned daily. Interview on 7/3/2024 at 1:50 p.m. with Resident #1, she said she noticed the cracked tiles, but she said she used her cane to go around it. She said her bathroom was cleaned sometimes. She said she was not sure when her floor had been mopped. Interview on 7/3/2024 at 2:55 p.m. with the DON, she said they had ambassador rounds to check in on resident and observe the rooms for repairs needed daily. She said she had been in her position for a week and was not sure which staff did the most recent ambassador round for Resident #1 and Resident #2's room. She said CNAs and Nurses should be rounding and reporting to maintenance when repairs were needed. She said Resident #1 was a fall risk because of the chipped tiles. Interview on 7/3/2024 at 3:05 p.m. with the Regional Consultant Nurse, she said the chipped tile (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675612 If continuation sheet Page 2 of 4 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 07/03/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was a safety hazard for residents that were a fall risk. She said they had identified the broken tile the day before. She there had not been any safety precautions to keep the residents safe from tripping hazards. She said the bathroom should be cleaned. She said everyone was responsible for ensuring rooms were kept in good repair and cleaned. Record review of facility policy Operations Policies and Procedures (revised 6/2019) revealed the following in part: Subject: Environmental: Resident's Room, Resident's Rights Policy: It is the policy of this facility that the Facility provides the resident with an environment that preserves dignity, privacy and contributes to a positive self-image. Resident rooms are designed and equipped for adequate nursing care comfort and privacy of residents. Promoting and preserving resident independence and self-sufficiency should be considered when arranging the resident living space. Procedures: . 13) The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. Record review of facility policy General Resident Area Cleaning/Disinfecting (revised 2/2022) revealed the following in part: Policies and Procedures Policy Routine cleaning of inpatient areas occurs while the patient is admitted , focuses on the patient zones, and aims to remove organic material and reduce microbial contamination to provide a visually clean environment. Procedure Routine Cleaning Daily High-Touch Surfaces, Floors, and Handwashing Sinks Weekly High Surfaces (above shoulder height) such as top of cupboards/vents Walls, Baseboards, Corners Monthly Window Blinds, Privacy Curtains (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675612 If continuation sheet Page 3 of 4 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 07/03/2024 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 0584 Annually Level of Harm - Minimal harm or potential for actual harm Window Curtains Resident Restrooms/Toilets Residents Affected - Few Clean and disinfect daily - .Considerations: sinks, handles, toilet seat, door handles, floor Resident Floors Floors generally have a low patient exposure and pose a low risk for pathogen transmission. Under normal conditions, they should be cleaned daily, but the use of disinfectant is not necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675612 If continuation sheet Page 4 of 4