Paradigm At The Pines

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

he/she should be contacted regardless of the time of day and made known of the event. The Administrator, Director of Nursing, or his/her will notify corporate director of clinical services and chief operating officer of any allegation or event concerning abuse, neglect, and/or exploitation. The Administrator, Director of Nursing, or his/her designee shall report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required and take all necessary corrective actions depending on the results of the investigation.

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

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Paradigm at the Pines

705 Hwy 418 W Silsbee, TX 77656

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Record review of the facility's policy Abuse, Neglect, Exploitation Prevention Policy and Procedure, date revised 09/10/2020, indicated Definitions: .Abuse is defined as the willful infliction of injury. Physical Abuse includes hitting, slapping, pinching and/or kicking.Reporting 1. It is the responsibility of all individuals who witness, or have knowledge of, an event regarding the abuse, neglect, and/or exploitation of any resident, regardless of the length of time between the actual event and his/her coming to knowledge of it, to immediately report it to the Administrator and/or Director of Nursing. If the Administrator or Director of Nursing is not present in the facility at the time, he/she should be contacted regardless of the time of day and made known of the event. The Administrator, Director of Nursing, or his/her will notify corporate director of clinical services and chief operating officer of any allegation or event concerning abuse, neglect, and/or exploitation. The Administrator, Director of Nursing, or his/her designee shall report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required and take all necessary corrective actions depending on the results of the investigation.

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

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Paradigm at the Pines

705 Hwy 418 W Silsbee, TX 77656

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 0610 Level of Harm - Minimal harm or potential for actual harm

leading up the alleged incident. 20. The facility investigation will be documented on the required state investigation form. 21. The administrator will provide the facility's completed investigation including witness statements and other supporting documentation to the state survey and certification agency with five (5) working days of the reported incident.

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

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Paradigm at the Pines

705 Hwy 418 W Silsbee, TX 77656

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 0657

assessment will be completed according to established procedures.

Level of Harm - Minimal harm or potential for actual harm 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

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Paradigm at the Pines

705 Hwy 418 W Silsbee, TX 77656

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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

During an interview on 09/09/25 at 02:10 p.m. LVN E said he had received in-service and had participated

in elopement drills they had conducted several times after the elopement. During an interview on 09/09/25 at 03:30 p.m. the UM said in-service and elopement drills had been received from 03/23/25 through 03/27/25. During an interview on 09/09/25 at 06:00 p.m.:* CNA D said she was the receptionist at the time of the elopement but had received in-service and participated in elopement drills several times after the elopement.* CNA G said she received elopement training while she was in the CNA class at the facility.* CNA H and CNA J said they received elopement training when they were hired by the facility. During interviews on 09/10/25:* at 10:20 a.m. CNA N said she had received in-service and participated in elopement drills several times after the elopement.* at 10:25 a.m. CNA O said she had received in-service and participated in elopement drills several times after the elopement.* at 10:28 a.m. CNA R said she had received in-service and participated in elopement drills several times after the elopement. Record review of

the Elopement policy revised 05/2024 indicated: Policy:The Facility will engage in active elopement prevention measures to mitigate the occurrence of elopement incidents. The Facility will deploy a prompt investigation and search if a resident is considered missing.Elopement Mitigation StrategiesThe Facility will implement the following mitigation strategies: Appropriateness of resident placement within the facility upon a::Jmission and during their stay. Completion of routine elopement risk assessments. Providing the resident with appropriate supervision. Completing environmental modifications as needed. Ensuring the resident's care plan is up to date. Conducting routine elopement drills. Having a resident photo in the electronic health record. Providing education for families, visitors, and volunteers. Conducting routine alarm checks/inspections. Initiate a manual monitoring system during power failure. On 09/09/25 at 05:40 p.m.,

the Administrator was informed of the Immediate Jeopardy. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 03/23/25 and ended on 03/27/25. The facility had corrected the noncompliance before survey began.

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

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Paradigm at the Pines

705 Hwy 418 W Silsbee, TX 77656

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 - Few

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

to the resident. She said not having the Inventory Sheet for a narcotic could lead to drug diversion. During

an interview on 09/09/25 at 04:25 p.m. the Administrator said she expected staff to follow policy regarding narcotic medications to prevent drug diversions and ensure residents receive their medication. Attempts were made to contact LVN X but recording indicated the caller was not taking calls. Attempts were made to contact RN Y and a message was left with no return call. Record review of the Narcotic Count policy revised 11/22 indicated the following: Policy: It is the policy of this facility to mitigate the risk of drug diversion by developing, implementing, and maintaining a narcotic count process. Procedures: The Narcotic Count and Inventory: 1. Controlled drugs will be counted every eight (8) - or twelve (12) -hour shift by authorized staff reporting on duty with the authorized staff reporting off duty.2. The inventory of controlled substances/drugs will be recorded on the Narcotic Records and signed for correctness of count.Process:1.

At the end of every eight (8) - or twelve (12) -hour shift the authorized staff member reporting on duty and

the authorized staff member reporting off duty meet at the designated medication cart or storage area to count controlled substances/drugs.2. The off-going authorized staff member reads down the controlled substance/drug Inventory Sheet one drug at a time.3. The oncoming authorized staff member counts the number of remaining controlled substance/drug and announces that number out loud.4. The off going authorized staff member checks this number against the Inventory Sheet. The remaining number is carried over to the controlled substance/drug Inventory Sheet for the new shift.5. Steps two (2) through four (4) are repeated for each controlled substance/drug in the inventory.

Event ID:

Facility ID:

If continuation sheet