Health inspection·August 28, 2025

F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some keep O2>90% every shift, disposable inner cannula (is a single-use plastic tube that fits inside the main, or outer, tracheostomy tube) every day shift change, oral care-every shift provide oral care, site dressing-every shift trach site clean.Record review of CR # 1's progress notes documented by LVN A, dated 8/21/2025 at 9:25 pm read in part change of condition identified dislodged tracheostomy tube. [ What do you think is going on with the resident. Nurse in patient's room for medication administration nurse noticed patient's trach is tilted to the side upon assessment when the 4x 4 gauze is removed the trach is observed laying on the patient's chest. An attempt made to replace the trach unsuccessful. The step-down trach unable to enter as well. [ CR # 1] oxygen saturation fluctuating 88%-91% patient bagged. Oxygen saturation increased to 97 %. 911 called, patient transferred to a {local hospital emergency room} for trach replacement.Record review of CR #1's hospital records, dated 8/22/2025, revealed, No distal tracheostomy tract appreciated with tracheoscopy, trach has likely been out for extended period. Stoma (a surgically created opening on the abdomen to an internal organ) significantly stenosed to size barely larger than flexible laryngoscope. Evidence of prolonged decannulation during SNF stay.Record review of CR # 1's hospital progress notes, dated 8/27/2025, read in part [CR # 1] was recently admitted to a local hospital on 6/19/2024 altered mental status , acute metabolic encephalopathy complicated by aspiration pneumonia which required prolonged intubation and eventually trach placement on 7/3/2025. [CR#1] was administered for respiratory monitoring due to trach dislodgement after an unknown period.Record review of Resident # 2's face sheet dated 8/28/2025 revealed Resident # 2 was a [AGE] year-old male that admitted to the facility on [DATE] with diagnoses of acute respiratory failure with hypoxia (a life-threatening condition where the lungs fail to adequately exchange oxygen and carbon dioxide, resulting in low blood oxygen levels), diabetes mellitus (a chronic metabolic disorder characterized by high blood sugar (glucose) levels), narcolepsy without cataplexy (a type of narcolepsy characterized by excessive daytime sleepiness (EDS) but without the sudden loss of muscle tone (cataplexy) that is typically associated with narcolepsy), and tracheostomy status ( refers to a patient having an existing tracheostomy, indicated by a stoma or opening in the neck to the windpipe (trachea), often using a tracheostomy tube).Record review of Resident # 2's MDS, dated [DATE], indicated Resident # 2 was unable to perform the BIMS. Resident # 2 was active diagnosis included Acute Respiratory Failure with Hypoxia (life-threatening condition where the lungs fail to adequately exchange oxygen and carbon dioxide, resulting in low blood oxygen levels) Resident # 2 was total dependent and required assistance of two people for all ADLs. Resident # 2 was always incontinent (unable to control) of bowel and bladder. Resident # 2 was unable to communicate. Resident # 2 rarely self-understood and rarely understood other. Record review of Resident # 2's care plan dated, 8/26/2025, revealed: Focus-Resident # 2 had a tracheostomy and is at risk for changes in secretions, infection, and respiratory distress. Goal: Resident # 2 would not experience no adverse effects through the review date (target date 9/8/2025). Interventions: conduct routine equipment maintenance and changes as indicated, emergency equipment: ambu bag (a portable, handheld device used to provide positive pressure ventilation to patients who are not breathing or are not breathing adequately), and spare trach (a crucial piece of emergency equipment for individuals with a tracheostomy, in case the original tube becomes dislodged, blocked, or damaged), encourage resident to keep head of bed elevated, follow physicians orders: O2 administration, medication administration, labs and x-rays, notify the physician of any adverse findings/changes, and observe for needed suctioning of increased secretions/congestion suctioning-assess for relief, observe for signs and symptoms of infection (redness, swelling, warmth, pain, increased secretions, malodorous secretions, bleeding), and provide tracheostomy site care as ordered. Record review of Resident # 3's face sheet, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675612 If continuation sheet Page 2 of 6 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 08/28/2025 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some dated 8/28/2025, revealed Resident # 3 was a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure with hypoxia (occur when there isn't enough oxygen in the blood), encephalopathy ( a general term for a condition that affects brain function), respiratory disorders in diseases classified elsewhere (lung or airway conditions caused by an underlying, systemic disease), and tracheostomy status (refers to a patient having an existing tracheostomy, indicated by a stoma or opening in the neck to the windpipe (trachea), often using a tracheostomy tube).Record review of Resident # 3's MDS, dated [DATE], re-entry from an acute hospital. Resident # 3 was unable to perform the BIMS. Resident # 3 was total dependent and required the assistance of two people for ADLs. Resident # 3 was always incontinent (unable to control) of bowel and bladder. Resident # 3 had a tracheostomy. Record review of Resident # 3's care plan, dated 8/26/2025, revealed it did not address he had a tracheostomy or the care of the tracheostomy.Record review of Resident # 4's face sheet, dated 8/28/2025, revealed Resident # 4 was a [AGE] year-old that admitted to the facility on [DATE] with diagnoses of cerebral infarction due to the thrombosis of right middle cerebral artery (an ischemic stroke where a clot blocks the right MCA (middle cerebral artery), starving a portion of the right brain of blood and oxygen) tracheostomy status, atrioventricular block (a condition where the electrical signals that control the heartbeat do not properly travel from the atria (upper chambers of the heart) to the ventricles (lower chambers)), and dependence on supplemental oxygen (the need for continuous or intermittent supplemental oxygen therapy to maintain adequate oxygen levels in the body).Record review of Resident # 4's MDS, dated [DATE], indicated Resident # 4 was unable to conduct BIMS. Resident # 4 was total dependent and required the assistance of two people for ADLs. Resident # 4 was always incontinent of bladder and bowel. Resident # 4 had a tracheostomy. Resident # 4 was unable to communicate with others. Record review of Resident # 4's care plan, dated 7/21/2025, revealed Focus: Resident# 4 had a tracheostomy related to chronic respiratory failure, and is at risk for increased secretion, congestion and infarctions; Goal: Resident # 4's secretions/congestion would be relived with suctioning or medications and will have no occurrence of infection over the next 90 days; Interventions: encourage Resident # 4 to keep head of bed elevated, ensure all equipment is in proper working order each shift, give medication per order-monitor labs/x-raysreport result to physician, keep extra same tracheostomy size equipment and /or next smaller size-down in room; observe for needed suctioning of increased secretions/congestion-provide suctioning -assess for relief, and observe for sign and symptoms of infection-report to physician. Record review of Resident # 5's face sheet dated, 8/28/2025, revealed Resident # 5 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of acute respiratory failure, unspecified whether with hypoxia or hypercapnia (a medical condition in which the lungs fail to adequately exchange oxygen and carbon dioxide gases in the blood), anoxic brain damage (a condition where the brain does not receive enough oxygen, leading to brain cell damage or death), and tracheostomy status. Record review of Resident # 5's MDS, dated [DATE] indicated Resident # 5 was unable to perform BIMS. Resident # 5 was total dependent and required the assistance of two people for all ADLs. Resident # 5 was always incontinent of bowel and had a foley catheter (tube into the bladder to drain urine). Resident # 5 had a tracheostomy. Resident # 5 was unable to communicate. Record review of Resident # 5's care plan, not dated, revealed: Focus: Resident # 5 had a tracheostomy and was at risk for changes in secretions, infection, and respiratory distress; Goal: Resident # 5's tracheostomy would experience no adverse effect through the review date (target date 8/31/2025); Interventions: conduct routine equipment maintenance and changes as indicated, emergency equipment: Ambu Bag and Spare Trach to bedside, encourage resident to keep head of bed elevated, follow Physicians orders: O2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675612 If continuation sheet Page 3 of 6 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 08/28/2025 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some administration, medication administration, labs and x-ray, notify the physician of any adverse findings and changes, observe for signs and symptoms of infection, and provide tracheostomy site care as ordered. Observation of Resident # 2 on 8/26/2025 at 11:06 am revealed he had an ambu bag and emergency tracheostomy supplies at the bedside as well as ample supplies of saline, suction tips and tubing including yankauer ( is a suctioning tool used in medical procedures) and was a 7 Shiley (type of breathing tube, specifically a tracheostomy tube) with adequate supplies of extra Shiley's at bedside. He had Jevity 1.5 hanging and infusing via pump at 85/hr. with water bolus infusing via pump as well at 40ml/hr. Both were dated and labeled 8/26/25. His tracheostomy tubing was connected via bedside concentrator at 4/L/min (refers to supplemental oxygen administered at a flow rate of 4 liters per minute) with humidified air water bottle dated 8/23/25 and trach tubing dated 8/26/25. O2 in use and EBP signs posted with EBP supplies readily available at bedside.Observation of Resident # 4 on 8/26/2025 at 11:37 a.m., revealed Resident # 4's O2 in use and EBP signs posted. Resident was resting in bed appropriately dressed and groomed. His call light was within reach and his facial beard was clean and trimmed as well as his fingernails. He had Jevity 1.5 infusing via pump at 65 ml/hr. with water bag flush connected and infusing via pump at 50 ml/hr. Both bags were dated 8/25/25. Resident was able to nod his head yes and no in response to questions, He nodded yes when asked if he was ok. His bedside concentrator was set at 5/L/min and infusing via trach tubing. Trach tubing was dated 8/25/25.Interview with the RT on 8/26/2025 at 11:28 a.m., she said that she provided facility nursing staff training at the facility yearly and prn. She said that training included return demonstrations and in-services on cleaning, maintenance and changing or trach as well as emergency care. Observation of CR # 1 on 8/27/2025 at 3:10 pm at a local hospital, revealed CR #1 was lying in bed asleep. CR # 1 did not have a tracheostomy at the time of this visit. Hospital Nurse A stated that CR# 1 was stable. Hospital Nurse A declined to provide any additional information regarding CR #1. Interview with the ADON on 8/26/2025 at 6:01 pm she stated that a Respiratory Therapist trained the nursing staff on Tracheostomy care. She stated she had not been trained on Tracheostomy care while working at this facility. Interview with the Administrator on 8/26/2025 at 6:15 pm, investigator inquired about tracheostomy training for nursing staff who were scheduled for 8/26/205 on the pm shift. (LVN A, LVN B, and LVN C). He stated that these nurses had not been trained by this facility on tracheostomy care. He stated he would conduct an Audit on Tracheostomy care training.Interview with LVN A on 8/26/2025 at 6:48 p.m., who said she was CR #1's charge nurse on the evening of 8/21/25. She said she did initial rounds at the beginning of her shift 6pm-6am which included checking CR #1 at the bedside, but only saying hello and CR #1 appeared to be breathing normally and in no apparent distress. LVN A said she did not notice any abnormalities with CR #1's tracheostomy at that time and continued her initial resident rounds. LVN A said she did not recall the time, but more than an hour later she returned to CR #1's bedside to provide medications and obtain vital signs and noticed CR #1's trach appeared to be at an angle, so she asked CNA A to assist her with repositioning the resident and when CR #1 was repositioned she noticed his entire tracheostomy was out and sitting on his chest below his chin. LVN A said she attempted to reinsert the tracheostomy canula but the surface of the stoma was closed. She grabbed the emergency kit at the bedside and attempted to utilize the step down (a downsized tube size) shiley (a type of tracheostomy tube) but that did not work either, so she initiated a code which included activation of 911. LVN A said they did not know how long CR #1's tracheostomy tube had been out. LVN A said she had not been trained at or by the facility to perform tracheostomy care. LVN A said she did not remember any competency or return demonstration trainings or assessments at this facility. Interview with LVN B on 8/26/2025 at 7:20pm revealed she worked at facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675612 If continuation sheet Page 4 of 6 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 08/28/2025 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some for 3 months and had not been trained or in-serviced on Trach care. She said she had worked with 1 current facility tracheostomy resident, CR # 1 and also worked the night CR #1 had his change in condition. LVN B said she did not attempt to reinsert CR #1's Tracheostomy tube on 8/21/25 because it did not look like it could be reinserted without causing additional trauma. LVN B explained that CR #'1 tracheostomy site appeared to have closed already. LVN B said she felt comfortable providing trach care to CR #1 even though she had not been trained by this facility on trach care. Interview with LVN C on 8/26/2025 at 7:37pm who said she had worked at facility for about 1 year and was trained tracheostomy care with a return demonstration about 3 weeks to a month ago. LVN C said the ADON did training with her early in the morning. LVN C said they had never done any training with an RT at this facility and never received trach training certificate at this facility. The surveyor notified the Administrator on 8/27/2025 at 1:15 pm., that they had a current Immediate Jeopardy related to respiratory/tracheostomy care. The IJ template was emailed to the to the Administrator on 8/27/2025 at 1:37 pm and a Plan of Removal was requested. The plan of removal was accepted on 8/27/2025 at 7:20 p.m. and included: Plan of Removal: Date: August 27, 2025 Immediate Action: According to the IJ Template, F695 Respiratory/Tracheostomy care and suctioning. The facility failed to ensure that CR # 1 who needed respiratory care, including tracheotomy care, circuit was attached appropriately causing it to become dislodged. The facility failed to ensure licensed nursing staff were trained to provide tracheostomy care. Resident #1 was transferred on 8/21/2025 to the ER and remains in the hospital.The four tracheostomy residents in house were assessed by the Respiratory Therapist and Director of Nursing on 8/27/25, residents were stable, and no signs of respiratory distress or complications were identified. The Respiratory Therapist validated that each resident had the correct tracheostomy supplies at bedside and the required emergency equipment readily available. On 8/27/25, the Respiratory Therapist provided tracheostomy care education and completed skill validation for the Director of Nursing. On 8/26/25, the Regional Nurse Consultant provided one-on-one training to the nurse on duty, covering tracheostomy care and suctioning procedures. A skills validation was completed during the session to ensure the nurse demonstrated competency with facility protocols. No issues were identified.Action: All licensed nursing staff will receive education and skills validation on tracheostomy care and suctioning, to be provided by a Respiratory Therapist and/or DON/ADON. The training will include: Routine tracheostomy care Suctioning of artificial airways Emergency response procedures, including accidental decannulation Signs and Symptoms of respiratory distress Oxygen TherapyA skills check-off will be completed to verify competency. Licensed nursing staff will not be allowed to work their next scheduled shift until both the education and competency validation have been completed. All newly hired licensed staff will receive this training as part of their orientation process. They will not be allowed to accept independent assignments until their skill check-off has been completed and approved by respiratory therapy or clinical leadership.Responsible: Director of Nursing Completion: August 28, 2025 Action: Ad Hoc QAPI conducted on 8/27/25 with Medical Director, Administrator, DON, & ADON regarding IJ F695.Responsible: Administrator/Director of NursingCompletion: August 27, 2025 Action: Administrator reviewed the facility policy for tracheostomy care and suctioning. No changes were made. Completion: August 27,2025 Monitoring: Observation of Resident #2 on 8/28/2025, revealed Resident # 2 was lying in bed and Resident # 2 did not display signs or symptoms of respiratory distress. A second emergency cannula kit was observed at the bedside. Observation of Resident # 3 on 8/28/2025 revealed Resident # 3 was lying in bed, and Resident # 3 did not display signs or symptoms of respiratory distress. A second emergency cannula kit was observed at the bedside. Observation of Resident # 4 on 8/28/2025 revealed Resident # 4 was lying in bed, and Resident # 4 did not display (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675612 If continuation sheet Page 5 of 6 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 08/28/2025 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete signs or symptoms of respiratory distress. A second emergency cannula kit was observed at the bedside. Observation of Resident # 5 on 8/28/2025 revealed Resident # 5 was lying in bed, and Resident # 5 did not display sign or symptoms of respiratory distress. A second emergency cannula kit was observed at the bedside. In a telephone interview with LVN B on 8/28/2025 at 11:10 am she stated that she was reeducated on 8/26/2025 by the Regional Nurse and the education included Respiratory training, education and competencies including tracheostomy care, administration of inhalation medication and oxygen services via tracheostomy and the location of the second cannula. She stated that she completed a returned demonstration, and she felt competent performing tracheostomy care. LVN B stated that she previously received tracheostomy training at another facility; she stated she could provide proof of this training. In a telephone interview with LVN C on 8/28/2025 at 11:25 am she stated that she was reeducated on 8/26/2025 by the Regional Nurse and the education included Respiratory training, education and competencies including tracheostomy care, administration of inhalation medication and oxygen services via tracheostomy and the location of the second cannula. She stated that she completed a returned demonstration, and she felt competent performing tracheostomy care. LVN C stated that she previously received tracheostomy training at another facility; she stated she could provide proof of this training. In a telephone interview with LVN A on 8/28/2025 at 2:15 pm she stated that she was reeducated on 8/26/2025 by the Regional Nurse and the education included Respiratory training, education and competencies including tracheostomy care, administration of inhalation medication and oxygen services via tracheostomy and the location of the second cannula. She stated that she completed a returned demonstration, and she felt competent in performing tracheostomy care. LVN A stated that she previously received tracheostomy training at another facility; she stated she could provide proof of this training. On 8/28/2025 telephone interviews were conducted with LVN D, LVN, E, LVN F, LVN G, LVN H, LVN I, LVN J, AND RN A. All staff stated they were in-serviced on tracheostomy care and management. All staff reported the completed a returned demonstration and felt competent in performing tracheostomy care. These staff worked various shifts to include morning shift, night shift and weekend shifts. Record review of the facility policies and procedures for Tracheostomy Management, dated 5/2022, revealed Licensed Nurses providing care for residents with tracheostomies will be trained on tracheostomy care. Precautions/Side Effect: accidental decannulation Record review of the facility policies and procedures for Tracheostomy Care, dated 11/22, read in part Tracheostomy care is performed aseptically for cleaning of the tracheostomy tube and soma site, to prevent plugging of the tracheostomy tube, to prevent airway obstruction, to prevent infection of trach site, and to maintain a patent airway for suctioning. Precaution /side effect(s): accidental decannulation. On 8/28/2025 at 4:13 p.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at a scope of pattern and a severity level of potential more than minimal harm that is not immediate jeopardy because all staff had not been trained on 8/26/2025. Event ID: Facility ID: 675612 If continuation sheet Page 6 of 6