Inspection·September 12, 2024

F 0759 Level of Harm - Minimal harm or potential for actual harm Review of Resident #35's quarterly MDS ([NAME] Data Set) dated 06/04/2024 section C Cognitive Patterns BIMS (Brief interview mental status) revealed resident score 15 (cognitively intact). Review of Resident 35's Care Plan dated 06/04/2024 revealed, Problem: The resident has Diabetes Mellitus. Goal-the resident will have no complications related to diabetes through the review date. Residents Affected - Some Review of Resident #37's electronic face sheet revealed, [AGE] year-old female admitted [DATE]. Diagnoses include Type 2 Diabetes Mellitus, Hypertension (high blood pressure), anxiety disorder. Review of Resident #37's Physician Orders dated 09/01/2024 revealed, Fiasp Flex touch pen 100 unit/ML (insulin aspart) inject per sliding scale. Review of Resident #37's annual MDS dated [DATE] revealed section C Cognitive Patterns BIMS score 15 (cognitively intact). Review of Resident #37's Care Plan dated 07/25/2024 revealed, Focus-The resident has Diabetes Mellitus. Goal- The resident will have no complications related to diabetes through the review date. InterventionsDiabetes medication as ordered by doctor. Monitor/document the side effects and effectiveness. Review of Resident #37's September 2024 MAR revealed Fiasp flex touch pen was administered per insulin sliding scale 11 days of 11 days. Fiasp Flex touch pen was administered 9 of 11 days 3 times per day and 2 of 11 days 2 times per day. During an interview on 09/10/2024 at 01:55 PM LVN A stated she did not prime the Fiasp flex touch pen before administration because she was not aware that the pen needed to be primed. LVN A stated this could lead to resident not getting all the insulin ordered. LVN A stated this could lead to resident's blood sugars to not be controlled. During an interview on 09/12/2024 at 11:24 AM the DON stated she was not aware of the need to waste/prime insulin pens before administration. The DON stated she did not feel that any residents were harmed by failing to prime insulin pens before administration. The DON stated this failure occurred due to not knowing insulin pens needed to be primed before administration. Review of facility's policy titled Insulin Injection Dated 01/13 Purpose to safely administer Subcutaneous Injection Expel air from the syringe Review of facility's policy titled Medication Administration dated 01/13 Purpose: To administer the following according to the principles of medication administration, including the right medication, to the right resident at the right time and in the right dose and routes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455611 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 455611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Care Center of Olney 1402 W Elm Olney, TX 76374 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were secured and stored in accordance with current accepted professional principles for 2 (West Hall Medication Cart and Treatment Cart) of 3 carts observed for medication storage. The facility did not ensure [NAME] Hall Medication Cart and Treatment Cart were locked and secure. This failure could place the residents at risk of gaining access to unlocked medications not prescribed to them. Findings included: Observation on 9/10/24 at 7:16 AM revealed treatment cart parked in [NAME] hallway corner near bathroom with a resident within 6 feet away of open, unsecured cart. No nurse in sight of cart. Present in cart were medicated dressings, prescription ointments and creams, over the counter creams. In an interview on 09/10/2024 at 7:18 AM L VN B stated that both LVNs had keys to treatment cart and it was both responsibility to ensure cart was secure. LVN B further stated the cart should be locked if not in use or sight of nurse and failure to secure cart could lead to residents accessing medications and treatment dressings in cart. Observation on 9/11/2024 at 6:30 PM revealed medication cart unlocked and unattended on [NAME] hall. Cart was parked in middle of hall and nurse was in resident room. Nurse was not in line of sight of medication cart. Present in medication cart included over the counter medications, prescription medications; narcotic drawer was locked by one lock. Interview on 9/11/2024 at 6:31 PM LVN C stated the medication cart was to be locked at all times to prevent resident accessing medications that could harm them. LVN C further stated that it was her responsibility to ensure the medication cart was locked. Interview with the DON on 9/12/24 at 10:22 AM revealed her expectation is for medication and treatment carts to always be locked if not in use by nurse. The DON also stated if cart is not locked residents could get into cart and have a possibility of drug diversion. The DON further stated that nurse who receives the cart is responsible for making sure it is secure. In an interview on 9/12/24 at 10:40 AM the ADM stated that medication carts should be locked if not in use. The ADM continued stating that lack of securing medication carts could potentially allow the wrong person to get in cart and get medications that did not belong to them. Record review of policy Medication Administration from Nursing Procedure Manual dated 01/13 revealed the following [in-part]: 14. Lock medication cart before entering resident/patient room. Never leave the medication cart open and unattended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455611 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 455611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Care Center of Olney 1402 W Elm Olney, TX 76374 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: Residents Affected - Some A. floors were swept and free from dirt and food crumbs. B. bottom shelves were clean. The facility's failure could place residents receiving oral nutritional intake at risk for foodborne illness and a decline in health status. The findings included: On 09/10/24 beginning at 6:40 AM, during the initial tour of kitchen, revealed refrigerator #1 had spilled, dry milk on the bottom in multiple areas, and underneath the shelves. In the corners and against the wall, there were dust and food crumbs. In the kitchen area, the floor was dirty with dirt and food crumbs and trash underneath the shelves and along the walls. In a follow-up interview and observation of the kitchen on 09/10/24 at 9:00 AM, there was no change in the soiled floors. In refrigerator #1, there was dry spilled milk in multiple areas and food crumbs underneath the shelves and along the bottom. The cleaning schedule posted and initialed by the assigned staff as task completed. In an interview with the Dietary Manager on 09/11/24 at 2:15 PM, The dietary manager stated the refrigerators were usually cleaned every Saturday by the evening cook but, she must not have done it last Saturday. She said there was a cleaning schedule that should be followed and initialed when the task was completed. She said that she was the person responsible for insuring the daily cleaning gets done but she is new to the job. She said she monitors the cleaning by checking the cleaning schedule for the employee's initials. On 09/10/24 at 2:30 PM review of the dietary cleaning schedule revealed several missing initials that signified that the cleaning tasks had been completed. In an interview with the Administrator on 09/12/24 at 3:00 PM, he said it was his expectation for the kitchen to be cleaned daily. If food was spilled, it should be cleaned up at that time. Failure to do so had the potential for infection and pests. A record review of the facility policy Cleaning and Disinfection of Environmental Surfaces, dated as revised August 2019, revealed the following [in part]: 9. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. A record review of the facility policy Professional Appearance in the Workplace, dated May 2022, revealed the following [in part]: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455611 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 455611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Care Center of Olney 1402 W Elm Olney, TX 76374 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 0812 Review of the Food and Drug Administration Food Code, dated 2017, specified [in part]: Level of Harm - Minimal harm or potential for actual harm 4-601.11 Residents Affected - Some Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455611 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 455611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Care Center of Olney 1402 W Elm Olney, TX 76374 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 1 (Resident #4) resident reviewed for infection control practices, in that: Residents Affected - Few LVN C failed to perform hand hygiene and change gloves as appropriate while providing incontinence care for Resident #4. This failure could place resident's risk for cross contamination and the spread of infection. Findings included: Review of Resident #4's face sheet, dated 09/12/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified dementia (memory loss), urinary tract infection, obesity (overweight) and depression (feeling of sadness). Review of Resident #4's Minimum Data Set (MDS) assessment dated on 07/26/24, revealed Resident #4 required dependence (helper does all effort) with most activities of daily living (ADLs) with two-person assistance. She was frequently incontinent of bowel and bladder. Active diagnosis revealed urinary tract infection. Review of Resident #4's physician order dated 8/8/24 revealed Resident #4 started new antibiotic medication Cefuroxime Axetil Oral Tablet 250 mg by mouth two times a day for ten days for urinary tract infection. Observation on 09/12/24 at 10:47 AM of incontinence care for Resident #4 revealed CNA D and CNA E transferred Resident #4 to bed side commode, LVN B removed the resident's brief. Resident #4 urinated and had bowel movement. CNA D and CNA E then assisted Resident #4 back to standing position. LVN B wiped the resident from front to back. LVN C gloves were soiled with urine and fecal matter but she continued to use. LVN C did not wash her hands, change gloves, or perform hand hygiene but proceeded to retrieve Resident #4's clean brief. LVN C placed the clean brief on the resident and fastened it. In an interview on 09/12/24 at 11:03 AM LVN C stated that after performing pericare her gloves were dirty. LVN C stated mixing clean with dirty was cross contamination and she should have performed hand hygiene with glove change in between. LVN C further stated that cross contamination can lead to infections. LVN C stated that she had received infection control training. During an interview with the DON 09/12/24 at 11:12 AM she stated the staff were expected to use proper infection control techniques, proper hand hygiene and change gloves at appropriate times. The DON further stated that lack of proper infection control techniques could cause infections such as urinary tract infections. The DON stated she was responsible for infection control in the facility. Review of the Perineal Care in Nursing Procedure Manual revised April 2013 revealed the following [in part]: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455611 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 455611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Care Center of Olney 1402 W Elm Olney, TX 76374 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 0880 Policy: To promote cleanliness and prevent infection. Level of Harm - Minimal harm or potential for actual harm Procedure: 13. Remove gloves, wash hands and apply clean gloves. Residents Affected - Few 14. Apply ordered creams or ointments and/or skin barrier cream to prevent breakdown as needed. Remove gloves, perform hand hygiene, and apply clean gloves. 15. Assist resident with incontinent brief, underwear, appropriate garments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455611 If continuation sheet Page 7 of 7