Health inspection·April 25, 2024

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 04/25/2024, at 09:18 a.m., revealed call bell system in shower stall #2 had an open electrical socket in shower room [ROOM NUMBER] with exposed wires. Observation on 04/25/2024, at 12:11 p.m., revealed call light system in shower #1 and call light system in shower stall #3 lit up when the call bell cords were pulled. Call light system in shower stall #2 had exposed wires and no emergency call light cord. Observation on 04/25/2024, at 12:28 p.m., revealed call light system in shower stall #2 in shower room [ROOM NUMBER] was covered with a plate cap and edges appeared to be sealed with a sealant. During an interview on 04/25/2024 at 09:07 a.m., the Maintenance Director stated his role with the facility began 04/23/2024. He stated that he had gone around the facility looking at bathrooms in resident rooms making notes of any needed repairs. He stated he had not been to the shower rooms and was not aware of any needed repairs. During an interview on 04/25/2024 at 09:54 a.m., Central Supply (CS) A stated she began her role with the facility on 04/23/2024 on the first shift. She stated that she was responsible for stocking supplies in the shower rooms daily. She was not aware of any repair needs in the shower rooms. She stated if she found repair needs, she would notify the maintenance department immediately. During an interview on 04/25/2024 at 10:27 a.m., CS B stated that she had worked the 2 p.m. to 10 p.m. shift until changing to as needed (PRN) 2-weeks ago. She stated she was responsible for providing showers to residents during her shifts in shower room [ROOM NUMBER] and had used all 3 shower stalls. She stated she was not aware of any plug plates or tiles missing, exposed wires in the shower stalls or missing call light cord. She stated if she had found the shower room in that condition, she would ensure the residents were safely out of the shower room, placed a sign on the shower room door that the shower room was out of order, start an in-service on reporting safety hazards and maintaining resident safety and notify maintenance. During an interview on 04/25/2024 at 11:03 a.m., the Utility Tech stated he had worked for the facility for the last 10 years. He stated he had been standing in as the maintenance director for the last 2-weeks while the role was being filled. He stated that he was not aware of any repairs needed in any of the shower rooms outside of a leaking pipe that was resolved last week. He stated that repair requests were added to the Maintenance Book located at the nursing station. He stated all staff were able to add repair requests to the book. He stated that it was the Maintenance Director's responsibility to check the maintenance book every morning and report the latest repair request during the daily morning meeting. He stated that the book would then be checked randomly throughout the shift and nursing staff also alerted him when a repair request was added to the book. He stated a new maintenance director started this week. During an interview on 04/25/2024 at 11:31 a.m., CNA A stated her shift at the facility was 6 a.m. to 2 p.m. and she had provided 5 showers on 04/25/2024 in the shower room [ROOM NUMBER]. She stated she had used 3 shower stalls including shower stall #2. She stated she noticed that the shower hose was not connected and connected it for use. She stated that she had not noticed exposed wires or the missing plate. She stated had she noticed it she would have reported to the supervisor. During an interview on 04/25/2024 at 11:43 a.m., the HRM translated for CNA B who stated that she began her role with the facility in October 2022. She stated she was on shift 04/25/2024 covering another staff's shift, but she normally worked the 2nd shift. She stated she had given residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676064 If continuation sheet Page 2 of 7 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 676064 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Katy 1480 Katy Flewellen Katy, TX 77494 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few showers in shower room [ROOM NUMBER] and used all 3-shower stalls at times. She stated that she had not seen any exposed wires or damages to any of the shower stall walls. During an interview on 04/25/2024 at 11:50 a.m., the HRM translated for CNA C who stated she had worked for the facility for 7-months and her shift was 6 a.m. to 2 p.m. She stated the last time she provided showers to residents in shower room [ROOM NUMBER] was about a month ago as the facility hired shower techs for the 1st and 2nd shift at that time. She stated she does not recall seeing any damages or exposed wires in shower room [ROOM NUMBER] at that time. During an interview on 04/25/2024 at 11:57 a.m., the HRM stated that the facility had 2-shower techs and Shower Tech (ST) A was on shift 04/25/2024. During an interview on 04/25/2024 at 11:59 a.m., CNA D stated she had been in her role at the facility since 2001 and she worked 6 a.m. to 2 p.m. she stated she had given showers to residents in shower room [ROOM NUMBER] about a month ago. She stated that she was not aware of any damages or missing tiles or covers in the shower stalls. She stated that sometimes she had to attach the shower hose in shower stall #2 before using. She stated if there were any damages, she would write in the maintenance book report and immediately report the repair to maintenance. During an interview on 04/25/2024 at 12:07 p.m., HRM translated for ST A who stated she had worked for the facility for 2-years and her shift at the facility was 6 a.m. to 2 p.m. Monday through Friday. She stated in her role, she had provided showers to residents in shower room [ROOM NUMBER]. She stated that she provided a shower to Resident #1 during her shift on 04/25/2024. She stated she was not aware of maintenance or repair needs in the shower room. She stated if any repairs were found she would report to the maintenance department immediately. During an interview on 04/25/2024 at 12:11 p.m., the Maintenance Director stated that the call light plate was missing from shower stall #2 in shower room [ROOM NUMBER]. He stated that the wires were exposed, but there was no power going through it. He could not say how he knew there had not been any power running through the wires. He stated any power running through the wires would have been at a low electrical voltage of 12 - 24 max. He stated that amount of power was equivalent to a direct current (DC) battery. He stated that if the wires were exposed to water, nothing would happen. When asked how he knew nothing would happen, he stated it would have been the same reaction of a flashlight falling in water. He stated he would place a plate cap over the area and seal the edges with waterproof sealant. During an interview on 04/25/2024 at 12:28 p.m., the Maintenance Director stated that the call light system in shower stall #2 in shower room [ROOM NUMBER] was covered with a plate cap and edges sealed with waterproof sealant. He stated that the sealant was dry, and no water could expose the wires. During an interview on 04/25/2024 at 12:35 p.m., Resident #1 stated that she took showers in shower room [ROOM NUMBER] at least 3-times a week. She stated in the a.m. of 04/25/2024 she was given a shower by ST A in shower stall #1. She stated that she had noticed the exposed wires in shower stall #2 and it had been that way for several months. She stated that she had never showered in shower stall #2 in fear that if the wires were exposed to water she would be electrocuted. During an interview on 04/25/2024 at 12:56 p.m., the Administrator stated that she was made aware of the exposed wires in shower room [ROOM NUMBER] by the DON. She stated that the Maintenance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676064 If continuation sheet Page 3 of 7 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 676064 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Katy 1480 Katy Flewellen Katy, TX 77494 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Director would make the needed repairs. She stated that staff were to report repair needs to the maintenance director and note the repairs in the maintenance book located at the nursing station. During an interview on 04/25/2024 at 01:43 p.m., the SVPCO stated that she was not aware of the exposed wires in shower room [ROOM NUMBER]. She stated that the maintenance director would repair the issue immediately. She stated that staff were to report repair needs to the maintenance director and write repairs in the maintenance logbook. During an interview on 04/25/2024 at 01:45 p.m., the DON stated that she was not aware of the exposed wires in shower room [ROOM NUMBER] prior to 04/25/2024. She stated that the maintenance director had made the repairs and she reported the repair needs to the Administrator. Record review of maintenance request logs for January, February, March, and April of 2024 revealed no repair requests for the call light system in shower room [ROOM NUMBER]. Record review of the Maintenance Service Policy Statement revised date December 2009 revealed: Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation: 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include but are not limited to: a. maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. maintaining the building in good repair and free from hazards. g. maintaining the paging system in good working order. The facility's shower sheets for 04/25/2024 were requested on 04/25/2024 at 12:20 p.m. from the DON and the Administrator but were not received. The facility's last 3 in-services on reporting repairs to maintenance requested on 04/25/2024 at 1:06 p.m. from DON and the Administrator but were not received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676064 If continuation sheet Page 4 of 7 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 676064 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Katy 1480 Katy Flewellen Katy, TX 77494 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or a centralized staff work area for 1 of 3 call light systems (call light #2) in 1 of 3 (shower stall #2) in 1 of 2 shower rooms (shower room [ROOM NUMBER]) reviewed for call lights. Residents Affected - Few The facility failed to ensure shower stall #2's emergency call light system in shower room [ROOM NUMBER] had a cord enabling it to be reachable from the floor. The facility failed to ensure that call light #2 in shower room [ROOM NUMBER] was maintained in safe operating condition. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life. Findings included: Record review of Resident #1's face sheet dated 04/25/2024 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including acute and chronic respiratory failure (difficulty breathing), and dependence on respirator [ventilator] status (mechanical devise that assists with pushing air into the lungs). Record review of Resident #1's annual MDS assessment dated [DATE] indicated she had a BIMS score of 15 which indicated she was cognitively intact. Record review of Resident #1's Care Plan undated indicated Focus: Resident at risk of falls: due to acute fall from bed. Edited 3/13/2024. Goals: Record review of the facility's incidents and accidents log dated 01/25/2024 through 04/25/2024 indicated that Resident #1 had an unwitnessed fall on 02/13/2024. Observation on 04/25/2024, at 09:18 a.m., revealed call bell system in shower stall #2 had an open electrical socket in shower room [ROOM NUMBER] with no call bell cord and exposed wiring. Observation on 04/25/2024, at 12:11 p.m., revealed call bell system in shower stall #2 in shower room [ROOM NUMBER] had exposed wires with no emergency cord available. Observation on 04/25/2024, at 12:28 p.m., revealed call light system in shower stall #2 in shower room [ROOM NUMBER] was covered with a plate cap and no emergency call bell cord. During an interview on 04/25/2024 at 09:07 a.m., the Maintenance Director stated he had not been to the shower rooms and was not aware of any needed repairs. During an interview on 04/25/2024 at 09:54 a.m., CS A stated she was not aware of any repair needs in the shower rooms. During an interview on 04/25/2024 at 10:27 a.m., CS B stated she was not aware of any issues with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676064 If continuation sheet Page 5 of 7 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 676064 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Katy 1480 Katy Flewellen Katy, TX 77494 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 0919 call bell systems in shower room [ROOM NUMBER]. Level of Harm - Minimal harm or potential for actual harm During an interview on 04/25/2024 at 11:03 a.m., the Utility Tech stated he was not aware of any repairs needed in any of the shower rooms or any inoperable call bells in the shower rooms. Residents Affected - Few During an interview on 04/25/2024 at 11:31 a.m., CNA A stated that she had provided 5 showers on 04/25/2024 in shower room [ROOM NUMBER] and had not noticed a missing call bell plate or cord. During an interview on 04/25/2024 at 11:43 a.m., the HRM translated for CNA B who stated she had given residents showers in shower room [ROOM NUMBER] and used all 3-shower stalls at times. She stated that she had not seen any exposed wires or damages or issues with the call bells. During an interview on 04/25/2024 at 11:50 a.m., the HRM translated for CNA C who stated the last time she provided showers to residents in shower room [ROOM NUMBER] was about a month ago, and she had not recalled seeing any damages or exposed wires in shower room [ROOM NUMBER]. During an interview on 04/25/2024 at 11:57 a.m., the HRM stated that the ST A was on shift 04/25/2024. During an interview on 04/25/2024 at 11:59 a.m., CNA D stated she had not given showers to residents in shower room [ROOM NUMBER] in about a month ago. She stated at that time she was not aware of any damages or missing tiles or covers in the shower stalls. During an interview on 04/25/2024 at 12:07 p.m., the HRM translated for ST A who stated she had provided a shower to Resident #1 during her shift on 04/25/2024. She stated she viewed no issues with the call bell systems. During an interview on 04/25/2024 at 12:11 p.m., the Maintenance Director stated that the call light plate was missing from shower stall #2 in shower room [ROOM NUMBER]. He stated that the wires were exposed, but there was no power going through it. He stated he would place a plate cap over the area and seal the edges with waterproof sealant. During an interview on 04/25/2024 at 12:28 p.m., the Maintenance Director stated that the call bell system in shower stall #2 in shower room [ROOM NUMBER] was covered with a plate cap and sealed. During an interview on 04/25/2024 at 12:35 p.m., Resident #1 stated that she took a shower in shower stall #1 in shower room [ROOM NUMBER] in the a.m. of 04/25/2024. She stated that she had noticed the exposed wires in shower stall #2 for several months. She stated that the call bell system in shower stall #1 worked. During an interview on 04/25/2024 at 12:56 p.m., the Administrator stated that she was made aware of the exposed wires in shower room [ROOM NUMBER] by the DON. She stated that the Maintenance Director would make the needed repairs. During an interview on 04/25/2024 at 01:43 p.m., the SVPCO stated that she was not aware of the exposed wires in shower room [ROOM NUMBER] or issues with the call bell system. During an interview on 04/25/2024 at 01:45 p.m., the DON stated that she was not aware of the exposed wires from the call bell system in shower stall #2 in shower room [ROOM NUMBER] prior to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676064 If continuation sheet Page 6 of 7 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 676064 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Paradigm at Katy 1480 Katy Flewellen Katy, TX 77494 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 0919 04/25/2024. Level of Harm - Minimal harm or potential for actual harm Record review of maintenance request logs for January, February, March, and April of 2024 revealed no repair requests for the call light system in shower room [ROOM NUMBER]. Residents Affected - Few Record review of Maintenance Service Policy Statement revised date December 2009 revealed: Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation: 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include but are not limited to: a. maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. maintaining the building in good repair and free from hazards. g. maintaining the paging system in good working order. A facility call bell policy was asked for on 04/25/2024 at 5:51 p.m. from the DON and the Administrator but were not received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676064 If continuation sheet Page 7 of 7