Health inspection·January 15, 2025

F 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for three of three resident hallways (B, C, D) and facility common areas reviewed for environment. 1. The facility failed to maintain two working HVAC units to distribute heat to halls B and C. 2. The facility failed to maintain temperatures in Halls B, C and D (rooms 201, 209, 211, 215, 313, 314, 315, 317, and 401) were above 71 degrees Fahrenheit (61-70 degrees Fahrenheit). An Immediate Jeopardy (IJ) was identified on 1/10/2025. The I.J. template was provided to the facility on 1/101/2025 at 5:14 p.m. While the IJ was removed on 1/15/2025, the facility remained out of compliance at a scope of widespread with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems . These deficient practices could place residents at risk of living in an unsafe, uncomfortable environment and decreased quality of life due. Findings included: Observations on 1/10/2025 at 12:08 p.m. - 1:24 p.m., revealed rooms on B and C halls had cold air blowing from the vents. Hallways B, C, D and the common area temperatures reflected the following (temperatures taken by the Acting Maintenance Dir .): o Hall B thermostat - 64 degrees Fahrenheit o Hall B common area - 57 degrees Fahrenheit o room [ROOM NUMBER] - 65 degrees Fahrenheit o Page 1 of 10 675612 675612 01/15/2025 Paradigm at Westbury 5201 S Willow Dr Houston, TX 77035

F 0584 room [ROOM NUMBER] - 67 degrees Fahrenheit Level of Harm - Immediate jeopardy to resident health or safety o Residents Affected - Many o room [ROOM NUMBER] - 68 degrees Fahrenheit room [ROOM NUMBER] - 65 degrees Fahrenheit o Hall C thermostat - 69 degrees Fahrenheit o room [ROOM NUMBER] - 66 degrees Fahrenheit o room [ROOM NUMBER] - 71 degrees Fahrenheit o room [ROOM NUMBER] - 65 degrees Fahrenheit o room [ROOM NUMBER] - 66 degrees Fahrenheit o Hall D thermostat - 70 degrees Fahrenheit o Hall D common area - 61 degrees Fahrenheit o room [ROOM NUMBER] - 62 degrees Fahrenheit Record review of Outside temperature reflected the following 1/9/25 low 37 degrees - high 41 degrees 1/10/25 low 37 degrees - high 43 degrees 1/11/25 low 33 degrees - high 41 degrees 675612 Page 2 of 10 675612 01/15/2025 Paradigm at Westbury 5201 S Willow Dr Houston, TX 77035

F 0584 1/12/25 low 41 degrees - high 51 degrees Level of Harm - Immediate jeopardy to resident health or safety 1/13/25 low 39 degrees - high 53 degrees Residents Affected - Many Interview on 1/10/2025 at 12:10 p.m., the Acting Maintenance Dir. said the heating system was not working properly and had been in and out within the past week. She said the HVAC vendor came out to the facility on 1/7/2025. She said the ADMIN and DON were aware the vendor came out and repairs were needed to the heating unit. She said it was not clear to her the unit was not blowing heat, and she assumed the repairs that were needed was not related to the HVAC system not blowing heat. She said there was a part that needed to be ordered. She said rooms were cold and the air was blowing cold without heat. She said Maintenance A had been checking the temperatures on the halls, but not in the resident rooms. She said she had not been instructed to place portable heaters throughout the facility . 1/14/25 low 39 degrees - high 52 degrees Interview and observation on 1/10/2025 at 12:15 p.m. revealed Resident #1 told the ADMIN he was cold. Resident #1 was in bed with a blanket over him . Resident #1 said he was cold, and the blankets were not enough to keep him wrong. Interview and observation on 1/101/2025 at 12:36 p.m., Resident #2 said he was cold. He was observed shivering. Resident #2 had one blanket that covered his waist down. The vent in the room was closed but blowing cold air which could be felt (68 degree Fahrenheit) (temperatures taken by the Acting Maintenance Dir.). The vent was directed toward Residents #2 and #5 head. Interview on 1/10/2025 at 1:17 p.m., Resident #3 said cold air was coming from the vent in his room (62 -64 degrees Fahrenheit - room [ROOM NUMBER] ) (temperatures taken by the facility staff). Resident #3 had on a sweater and jeans. He had a thin blanket on his bed . Interview on 1/10/2025 at 12:45 p.m., the ADMIN said the HVAC vendor was out to the facility on the 1/7/2025 to attempt to make repairs. She said 1/6/2024 was her first full day in the facility since she started on 12/20/2025. She said she was not told cold air was being blown through the vents. She said she instructed Maintenance A to update her when the temperatures fell below 72 degrees in the facility on 1/7/2025. The ADMIN said she was told by Maintenance A and the Acting Maintenance Dir. the temperatures had not fallen below 72 degrees. She said she was told in the morning meeting (approximately 9:00 a.m. on 1/10/2025) by a staff who performed angel rounds (routine rounds to check on residents), the rooms were cold. She said she had not checked the temperatures on the halls or checked how the temperatures felt in the residents' rooms of halls B and C because she was told the temperatures had not fallen below 72 degrees She said there were parts needed to repair the HVAC system. She said she was informed the HVAC system was in and out by Maintenance A and the Acting Maintenance Dir. She said because she had not been in the building full time and was not aware the HVAC heating system was not functioning properly. Interview on 1/10/2025 at 1:17 p.m., Maintenance A said the HVAC system on B and C hall was in and out for a few weeks. He said he was told to take the temperatures and let the ADMIN know if it fell below 72 degrees. He said he did not check the resident rooms or the vents. He said the HVAC vendor came out on 1/7/2025 and he needed to order parts. He said the parts would be in on 1/12/2025. He said the facility was not allowed to put in portable heaters. He said he had not turned off the HVAC unit from blowing cold air. He said the heat was not working. 675612 Page 3 of 10 675612 01/15/2025 Paradigm at Westbury 5201 S Willow Dr Houston, TX 77035

F 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Interview on 1/10/2025 at 1:47 p.m., the ADMIN said she needed to contact the HVAC vendor and get an update on what repairs were needed. She said she would have to contact her corporate management and request portable industrial heaters, since the current units were not blowing heat. Interview on 1/10/2025 at 2:42 p.m., the DON said cold temperatures and residents shivering would indicate the environment was not comfortable. She said she had not instructed the nursing staff to monitor room temperatures or signs and symptoms related to the cold temperatures. She said the resident rooms were cold but she was not aware prior to surveyor intervention. Interview on 1/10/2025 at 3:19 p.m., the ADMIN said the HVAC vendor closed the vents on 1/7/2025 when the temperatures dropped outside in order to stop the cold air that was blowing from the HVAC system. She said they thought by closing the vents it would prevent the room temperatures from dropping even further. She said the facility had approximately 8-10 small heaters that could be used in resident rooms. Interview on 1/10/2025 at 5:01 p.m., the ADMIN said the HVAC vendor needed to secure an electrician because two relays (mechanisms that turn a unit on and off when it reaches a certain temperature) needed to be installed on Hall B. She said this would take about 10-15 minutes to install. Observation on 1/10/2025 at 5:30 p.m. revealed the room temperatures for Hall B (B5, B7 - thermostats) was 67 degrees Fahrenheit and 64 degrees Fahrenheit (temperatures taken by the facility staff). Record review of the facility's policy Emergency Preparedness - Loss of Heating Element (revised date 11/20/2024) revealed the following: Policy - Emergency Preparedness - Loss of Heating Element Policies and Procedures Policy The Facility will ensure the safety and comfort of residents, staff, and visitors in the event of heating system failure, this policy provides guidelines to maintain safe indoor temperatures and minimize risks during cold conditions. Procedure I. Initial Response: Notify the Maintenance Director and Administrator immediately. Contact a licensed HVAC professional to assess and repair the heating system. Ensure the repair company can respond promptly and is familiar with the facility's equipment. 2. Temperature Monitoring: Begin routinely monitoring and recording indoor temperatures in all resident rooms and common 675612 Page 4 of 10 675612 01/15/2025 Paradigm at Westbury 5201 S Willow Dr Houston, TX 77035

F 0584 areas. Level of Harm - Immediate jeopardy to resident health or safety 3. Residents Affected - Many Provide residents with extra clothing, blankets, and thermal wear as needed. Resident Safety and Comfort: Relocate residents to warmer areas of the facility if temperatures become unsafe in their rooms. Distribute portable heating elements to maintain comfort in common areas and resident rooms, following fire safety guidelines. 4. Resident Assessment and Monitoring: Nursing staff will assess residents for signs of hypothermia or cold stress as indicated. Increase fluid intake and provide warm beverages or meals, ensuring dietary needs are met. Notify the resident's physician if a resident shows signs of cold-related health concerns. 5. Staff Coordination: Assign additional staff to assist with monitoring residents and maintaining communication with families. Provide staff with clear instructions on their roles and expectations during the event. 6. Communication: Notify residents, families, and responsible parties about the heating issue and actions being taken. 7. Regulatory Compliance: Self-Report Heating Element Loss. Maintain all documentation, including repair logs, temperature records, resident assessments, and communication efforts, for survey readiness . An IJ was identified on 1/10/2025. The IJ template was provided to the Administrator and the DON on 675612 Page 5 of 10 675612 01/15/2025 Paradigm at Westbury 5201 S Willow Dr Houston, TX 77035

F 0584 1/10/2025 at 5:14 p.m. Level of Harm - Immediate jeopardy to resident health or safety The following Plan of Removal submitted by the facility was accepted on 1/11/2025 at 7:48 p.m.: Residents Affected - Many Name of facility: [Facility] PLAN OF REMOVAL Date: 01/10/2025 According to the IJ Template the facility failed to ensure to maintain safe and comfortable temperatures throughout the building when heating units were not functioning for 3 days. Immediate Action Taken 1. On 01/10/2025 DON assessed Residents #1, #2, #3, #4 affected by the uncomfortable temperature and were provided extra blankets and nursing added layers of clothing on affected residents. Residents were offered to be taken to the dining room where the HVAC is operating. Nursing staff immediately began monitoring resident's vitals, temperature, and any other cold-related health concerns. MD was notified and no new orders were given. 2. DON assessed 100% of the residents and identified that no other residents were to be at risk. 01/10/2025. 3. On 01/10/2025 facility purchased anti-tip portal heaters HVAC vendor was contacted to request industrial portable heaters. On 01/10/2025 HVAC vendor arrived and installed 4 industrial portable heaters to compensate for the HVAC failure and will remain in place until HVAC is repaired. 4. On 1/10/25 the administrator and maintenance supervisor routinely rechecked temperatures on Hall B 72, Hall C 70, Hall D 75, room [ROOM NUMBER] room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], Common Area B, room [ROOM NUMBER], room [ROOM NUMBER] and readjusted the temporary HVAC unit until the temperatures reached 71 degrees. On 01/11/2025 temp was 71 degrees. The maintenance director/trained designee will conduct the temperature checks every 2 hours and make adjustment to the temporary heating unit as needed until HVAC is fixed. The administrator will oversee the temperature log for accuracy. 5. On 01/10/2025 a regional contractor assessed the HVAC unit and determined the heater exchange was not functioning, and on 01/11/2025 a certified HVAC specialist conducted a follow-up assessment. Contractor revealed transmitter conductor was not connected. When contractor connected the conductor the 675612 Page 6 of 10 675612 01/15/2025 Paradigm at Westbury 5201 S Willow Dr Houston, TX 77035

F 0584 Level of Harm - Immediate jeopardy to resident health or safety HVAC unit started working and hot air started blowing out in the front section of Hall B. The shorter section of Hall B and Hall C require a higher voltage electric wire, requiring electrician to install and then heater exchanger needs to be installed. On 01/13/25 electrician will come to the facility to connect the higher voltage that is required on hallway B and C. 01/13/2025 is the anticipated repair date for when the heater exchange needs to be installed and when the contractor connected the conductor. Residents Affected - Many Facilities [sic] Plan to ensure compliance quickly 1. On 01/10/2025 Administrator and DON reviewed Policies and Procedures for Emergency Preparedness on Loss of Heating Element which will include Educating Staff on Initial Response, How to Monitor Temperature, Ensuring Resident Safety and Comfort, Completing Resident Assessment and Monitoring, Staffing Coordination, Notifying families, and Regulatory Compliance. No change was needed. 2. On 01/10/2025 the Regional Nurse Consultant educated DON and Administrator on emergency preparedness- loss of heating element- topics to include initial response, temperature monitoring, resident safety and comfort, resident assessment and monitoring, communication and regulatory compliance. 3. On 1/10/25 The Administrator and DON educated all staff on emergency preparedness heating elements to include initial response, temperature monitoring, resident safety and comfort, resident assessment and monitoring, communication and regulatory compliance, and reporting failure of HVAC system and temperatures outside of normal range to administrator immediately. Staff will receive education before start 4. On 1/10/25 The Administrator educated the Acting Maintenance Director on routine temperature check for HVAC failure and reporting temperature outside of normal range. Educated to also include emergency On 01/10/2025 Administrator and DON completed an Ahoc QAPI with Medical Director regarding the Immediate Jeopardy the facility received related to the F921: Safe/Functional/Sanitary/Comfortable/Environment and reviewed plan to sustain compliance. Monitoring of the plan of removal included the following: Observation on 1/11/2025 at 7:58 p.m. revealed temporary industrial heating units were being utilized on Units B (2 industrial heaters), Main common area (1 industrial heater), and Unit C (1 industrial heater). Parts of Unit B and Unit C had temperatures below 72 degrees Fahrenheit (Thermostat B7 on Unit B was 68 degrees Fahrenheit, room [ROOM NUMBER] was 71 degrees Fahrenheit, room [ROOM NUMBER] was 65 degrees Fahrenheit, room [ROOM NUMBER] was 69 degrees Fahrenheit, Unit C - room [ROOM NUMBER] was 66 degrees Fahrenheit, room [ROOM NUMBER] was 65 degrees Fahrenheit, room [ROOM NUMBER] was 66 675612 Page 7 of 10 675612 01/15/2025 Paradigm at Westbury 5201 S Willow Dr Houston, TX 77035

F 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many degrees Fahrenheit, room [ROOM NUMBER] was 67 degrees Fahrenheit, and room [ROOM NUMBER] was 66 degrees Fahrenheit). Residents were observed to have blankets, appropriate clothing, and small heaters (specific rooms and common areas). Observations on 1/11/2025 at 8:00 p.m. revealed signs posted at all nursing stations revealed Monitor Resident For: Shivering, Numbness, Change of Skin Color, Decreased Temperature, and Dry Mucus Membranes. Observations on 1/12/2025 - 1/15/2025 revealed temporary industrial heating units were being utilized on Units B (2 industrial heaters), Main common area (1 industrial heater), and Unit C (1 industrial heater) remained in use until the 2 HVAC units were repaired and the heater for Units B and C were able to maintain a temperature above 71 degrees Fahrenheit. Observation and interview on 1/11/2025 at 8:15 p.m. revealed Resident #1 in bed with two blankets over him. He said he was warm. Resident #1 had a small portable heater in the room and the temperature was 76 degrees Fahrenheit. Observation and interview on 1/11/2025 at 8:19 p.m. revealed Resident #2 had a small portable heater in his room. He said the small heater made a difference, and he was no longer shivering. The temperature was 71 degrees Fahrenheit. Observation on 1/12/2025 at 5:40 p.m. of Resident #3 and Resident #4's room revealed the temperature was 74 degrees Fahrenheit. Observation on 1/13/2025 at 10:06 a.m. revealed temperatures in the common areas, resident room ranged from 67 -78 degrees Fahrenheit. Observation on 1/14/2025 at 3:53 p.m. revealed temperatures in the facility ranged from 73-85 degrees Fahrenheit on Halls A, B, C, and D. Observation on 1/15/2025 at 10:35 p.m. revealed temperatures in the facility ranged from 73-75 degrees Fahrenheit on Halls A, B, C, and D. Interviews were conducted on 1/11/2025 - 1/14/2025 with staff on all shifts RN A, RN B, RN C (day), RN D, LVN B (night) - (Nurses 6:00 a.m. - 6:00 p.m., 6:00 p.m. - 6:00 a.m.), CNA A, CNA B, CMA A (day), CNA C, CNA D (night), CNA E , CNA F (morning)- (6:00 a.m. - 2:00 p.m., 2:00 p.m. - 10:00 p.m., and 10:00 p.m. 6:00 a.m.), the DON, ADON, ADMIN, Maintenance A, Maintenance Dir., Former Acting Maintenance Dir., HK Supervisor, and Activity Director to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding related to emergency preparedness heating elements to include initial response, temperature monitoring, resident safety and comfort, resident assessment and monitoring, communication and regulatory compliance, and reporting failure of HVAC system and temperatures outside of normal range to administrator immediately . Nursing staff reported they monitored residents hourly, checked for signs and symptoms of hypothermia (condition of having a lower body temperature than normal) like shivering, skin color, numbness, offered. Interview on 1/12/2025 at 5:25 p.m., Resident #6 said she did not have any complaints and the nursing staff came into her room to ensure she was comfortable, warm and they checked her vitals. 675612 Page 8 of 10 675612 01/15/2025 Paradigm at Westbury 5201 S Willow Dr Houston, TX 77035

F 0584 Level of Harm - Immediate jeopardy to resident health or safety Interview on 1/14/2025 at 3:28 p.m., Maintenance A said the 2 new HVAC units were installed, wired and the appropriate breaker to support the wattage was installed. He said he would begin to open the vents in rooms to ensure the warm air was flowing. He said the temperature was set high but would adjust the temperature to an appropriate level. Record review of the facility's document Ad Hoc QAPI dated 1/10/2025 revealed the following in part: Residents Affected - Many On 01/10/2025 [Facility] to ensure to maintain safe and comfortable temperatures throughout the building when heating units were not functioning for 3 days. Root Cause Analysis: Inclement weather with outside temperatures as low as 38 degrees and high 50 degrees. On 01/10/2025 residents observed to cold due to vent blowing cold air Record review of nurses' notes and vitals dated 1/10/2025 - 1/15/2025, for all affected residents revealed nurses documented monitoring of resident vitals which included resident temperatures were within normal range. Record review of the facility's Temperature logs, dated 1/10/2025 - 1/15/2025, revealed all halls (including Hall B 72, Hall C 70, Hall D 75 (thermostat), room [ROOM NUMBER] room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], Common Area B, room [ROOM NUMBER], room [ROOM NUMBER]) temperatures were monitored hourly until the two HVAC heating units were repaired. Record review of the facility's Education In-Service Attendance Record - Monitoring Temperatures, dated 1/10/2025, by the ADMIN to the HK Supervisor, Maintenance A, and HK A. Summary of training session Monitor temperature on specified hallways and keep updated logs of monitoring. Notify [ADMIN] [phone number] of any temperature less than 72 degrees Fahrenheit. Record review of the facility's Education In-Service Attendance Record - Emergency Preparedness - Loss of Heating Element, dated 1/10/2025 by RNC to the DON and ADMIN. Record review of the facility's receipt, dated 1/11/2025, for 21 additional blankets. Observation on 1/11/2025 at 7:58 p.m. revealed temporary industrial heating units were being utilized on Units B (2 industrial heaters), Main common area (1 industrial heater), and Unit C (1 industrial heater). Parts of Unit B and Unit C had temperatures below 72 degrees Fahrenheit (Thermostat B7 on Unit B was 68 degrees Fahrenheit, room [ROOM NUMBER] was 71 degrees Fahrenheit, room [ROOM NUMBER] was 65 degrees Fahrenheit, room [ROOM NUMBER] was 69 degrees Fahrenheit, Unit C - room [ROOM NUMBER] was 66 degrees Fahrenheit, room [ROOM NUMBER] was 65 degrees Fahrenheit, room [ROOM NUMBER] was 66 degrees Fahrenheit, room [ROOM NUMBER] was 67 degrees Fahrenheit, and room [ROOM NUMBER] was 66 degrees Fahrenheit). Residents were observed to have blankets, appropriate clothing, and small heaters (specific rooms and common areas). Record review of the facility's email written by the ADMIN, dated 1/13/2025 at 1:53 p.m., in response to the question if there was an update on repairs revealed the following: Yes, just now. Corporate has approved full installation on HVAC units for B, C Hall. This is in addition to the work 675612 Page 9 of 10 675612 01/15/2025 Paradigm at Westbury 5201 S Willow Dr Houston, TX 77035

F 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many getting done today. Full installation should be completed today. The goal is to have a fully functional system with zero space heaters and auxiliary heaters in the facility. Record review of HVAC vendor email, dated 1/10/2025 at 5:52 p.m. revealed the following: Upon thorough assessment of the system, it was determined that specific parts were required to address the identified issues. These parts were promptly ordered on January 7, 2025. The scheduled installation of the ordered parts is planned for January 12, 2025, to ensure the HVAC system is restored to proper working condition Record review of HVAC vendor email (dated 1/11/2025 at 4:18 p.m.) revealed the following: I am writing to provide an update on the measures we have taken to address the heating issues at [Facility, located at [Facility Address] On 01/11/2025, I dispatched an HVAC technician to assess and service the two malfunctioning heating units. While the technician was able to keep the units operational, they are not currently functioning at full capacity. To mitigate the impact on the affected areas, we delivered Four 1.25-ton portable .heat pump units yesterday and placed them in the hallways needing supplemental heat. Additionally, this morning, we delivered five more portable heaters, strategically placing them in the affected areas to ensure warmth throughout the facility. This afternoon, the HVAC technician returned to inspect the units again to confirm they are still providing some heat. I will continue to send the technician daily to monitor and maintain the heating units as best as possible while repairs are underway. Furthermore, the portable heaters will remain in place until the issue with the heating units is fully resolved The Administrator was informed the Immediate Jeopardy was removed on 1/15/2025 at 4:13 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of widespread due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 675612 Page 10 of 10