Paradigm At The Oak

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

until Resident #2 was sent out. He said the possible negative effect of Resident #2 being transferred to a facility with no guardian was that Resident #2 would have no RP. Record review facility policy Discharge Transfer Policy dated June 2024 reflected the facility was committed to ensuring safe discharge dispositions and would make every effort to facilitate a smooth transition of care. In some cases of difficult or immediate discharges, the facility will follow Centers for Medicare & Medicaid Services and state guidelines to maintain regulatory compliance and protect resident's rights and well-being. Procedures - common discharge/transfer rationales include the transfer, or discharge is necessary for the resident's welfare and

the resident's needs cannot be met in the facility. Behavioral issues that cannot be safely managed in the current setting that endanger other individuals within the facility. The facility will provide the residents with a discharge summary that recaps their stay outlines the discharge plan of care and includes a discharge medication reconciliation listing and instructions. The resident, the resident's representative and the long-term care ombudsman program will receive written notice of discharge at least 30 days before the planned discharge date in a language and manner the resident can understand. The notice will include the reason, effective date, and location of the discharge. A statement that informs the resident of his or her rights to appeal the discharge by requesting a hearing through the Health and Human Services Commission within 90 days.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Paradigm at the Oak

507 West Ave Schulenburg, TX 78956

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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

plan, was possible injury to the resident. Interview on 09/22/25 at 4:11 pm with AN LVN reflected she admitted Resident #3 into the facility. She said when a resident was admitted , it included how to transfer

the resident when they arrived at the facility. She said that Resident #2 was transferred by a mechanical lift, but she had never transferred Resident #2. She said she had access to the care plan, she looked at it and if there were adjustments that needed to be made to the care plan, she could go into the care plan and make adjustments. She said everybody was responsible for care plans, but she did not know who was directly responsible for care plans. She said a possible negative effect of a person not being transferred in accordance with the care plan was injury. Review of facility baseline care policy dated May 2022 reflected that the facility will implement a baseline care plan to ensure continuity of care and communication, prevent adverse events, and inform the resident and or responsible party of the initial care and services. Procedure - a baseline care plan will be developed within 48 hours of admission. At minimum, a baseline care plan will address initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and PASRR recommendations.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Paradigm at the Oak

507 West Ave Schulenburg, TX 78956

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

the MA B reflected the number 8 in a residents' MAR meant pending delivery of a medication and the medication was not administered to the resident because the facility did not have it. When Resident #3 first arrived, the pharmacy was not sending his lidocaine patch. She did not know why. She said everyone knew about it, the ADON, DON, and the nurses. She said she informed the nurses, and they would get some into

the facility, but they would run out quickly. She said she asked Resident #3 if he only wanted 1 patch to make them last longer and she would only give him one patch. She said sometimes they were purchased from [name of discount store]. She said the DON was responsible for making sure all medications for the residents were in the building. She said the possible negative effect of him not getting his lidocaine patches would be that he was in pain.Interview on 09/22/25 at 7:13 pm with Resident #3 reflected he did not get his lidocaine patch about 20% of the time and he did not receive other medications, he believed, intentionally.

He said he felt neglected because he did not get his medication.Interview on 09/22/25 at 7:25 pm with LVN D reflected MAs notified the DON one or two times that Resident #3 did not receive his lidocaine patch. The pharmacy informed her that it was an over-the-counter medication unless there was a consent form signed and then it could be sent out to the facility. She thinks she told this to the people in the morning meeting.

She said she did not remember who was at the meeting. She said it was the responsibility of everyone on

the team to make sure that all of the medications for residents were in the building. She said the possible negative effects of Resident #3 not receiving his medication was that the resident could have been in pain.

Interview on 09/22/25 at 7:54 pm with the DON reflected Resident #3 was not getting his lidocaine patches because there was a problem with availability. The DON said sometimes Resident #3 would get one patch administered instead of two patches administered and this was not good medication administration. He said

he saw no information to indicate that the NP was told Resident #3 was not getting the lidocaine patches.

He said if there were blanks in the MAR for a medication means the medication was not given or was skipped. The DON said residents should receive all the medications prescribed to them. The DON said that

the negative effect of a residents not getting their medication was that the medication did not sustain its sufficiency to maintain the efficiency of the medication or the effects of the medications. He said the negative effect of Resident #3 not getting his lidocaine patch was that he would not get the desired pain management. He said it was the responsibility of the person giving the medications to make sure that residents' medications were in the facility. He said if the medication was not given the medical doctor or NP and the RP should be notified. He said the MAs or the nurse should call the pharmacy to figure out why the medication was not there and tell the DON. He said all steps and phone calls should be documented in the residents' progress notes.Interview on 09/23/25 at 2:35 pm with the Administrator reflected the DON was responsible for making sure that medications were in the building properly administered and the administration of the medications was properly documented. She said the possible negative effects of residents not receiving their medication was that they could experience pain. She said if the doctor ordered

the medications, Resident #3 needed to be administered the medications.Record review of facility Nursing Policies and Procedures Medication Management dated June 2019 reflected the facility It is the policy of

the facility that the facility will implement a Medication Management Program that incorporates systems with established goals to meet each resident's needs as well as regulatory requirements. The facility's Medical Director will have an active role in the oversight of medication management.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Paradigm at the Oak

507 West Ave Schulenburg, TX 78956

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 0804 Level of Harm - Minimal harm or potential for actual harm

holding, serving, delivery, cooling and reheating. Review of facility food Palatability policy, dated 11/31/24, reflected food temperatures were monitored prior to service to ensure palatability and safe point-of-service temperatures.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Paradigm at the Oak

507 West Ave Schulenburg, TX 78956

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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

she told the administrator at the time about it, the MD, and the charge nurse. She said it was a big part of her reason she previously left the facility.Interview on 09/22/25 at 7:54 pm with the DON reflected there were bugs in the facility, and it was a problem because it could create skin abrasions and bites. He said roaches could be an infection control issue because they represented a dirty environment. He said he told

the Administrator Resident #3 kept food in his room and mice might eat his food, so the Administrator got a plastic container for his food. The DON said Resident #3 should have been moved as soon as it was confirmed there were rat droppings in his room. He said the negative effect of a rodent in a resident's room was the possibility of being bitten by the rodent and skin infection. A rodent in Resident #3's room was definitely more difficult for him because Resident #3 could not move.Interview on 09/23/25 at 2:35 pm with

the Administrator reflected that she could not remember when they brought up the possible rodent situation

in Resident #2's room. She said both she and the MD went into Resident #2's room with a flashlight and looked around. She said they did not see anything but there was gap in the floorboard which the MD filled with a foam substance. She said on 09/19/25 the charge nurse called her and said the night agency nurse said she saw a rat running through Resident #2's room. The Administrator thought Resident #2 was delusional because he said it was a possum and Resident #2 had UTIs. The administrator said the MD said Resident #2 made stuff up. They now know there was a rodent in the facility because it was reported by a nurse.Interview on 09/23/25 at 2:35 pm with the Administrator reflected she had not seen live bugs in the facility. She said she did not know if having rodents and bugs in the facility was an infection control issue.

She said the facility was supposed to have a homelike environment and people who do not live at nursing facilities have bugs and rodents even though they do not want to. She said the facility tried to keep bugs and rodents out of the facility just like people who do not live in nursing facilities.Record review of facility Policies and Procedures Pest Control dated June 2024 reflected the facility will implement measures to prevent, monitor, and address pest activity in a manner that does not compromise resident safety, infection control, or environmental standards.

Event ID:

Facility ID:

If continuation sheet