Inspection·December 11, 2025

F 0640 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete assessments were very important and it shows the true picture of the resident to create a person-centered care plan that would assist staff in providing the best care possible for the resident, further stating that when completing an admission assessment it must be signed and submitted to CMS within 14 days. The VPCO then stated an adverse outcome would be the staff not knowing or understanding how to take care of a resident making the assessments very important. During an interview on 12/11/2025 at 4:16pm with VPCR, she stated that she had 20 years of experience with MDS Assessments. She stated the expectation that the assessments, admission or significant change, were completed and showed a full picture of the residents to create a care plan that would assist the staff in providing the best care for the residents. She then stated the assessments must be submitted to CMS with 14 days of admission and an adverse outcome would be the care plan doesn't get completed and then it doesn't show the staff how to take care of the residents. During an interview on 12/11/2025 at 4:45pm with ADMN (administrator) stated he had only been at this facility as the interim administrator for 2 weeks. He stated from what he knows, the MDS assessments do have a time limit on how long they have to submit them to Medicare but he wasn't completely sure on dates. The ADMN acknowledged the 2 MDS assessments for Resident #1 and #12 should have been submitted way before that day. He further stated it was important to complete all assessments in a timely manner, and he would be following up on this to make sure it was taken care of. Record review of the policy named MDS 3.0 Completion not dated revealed [in part]:Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Policy Explanation and Compliance Guidelines:#7. Transmission Requirements:a. All assessments shall be transmitted to designated CMS system (iQIES) within 14 days of completion.b. Each assessment must be accepted into the system, as verified by validation reports. Record review of the CMS RAI 3.0 Manual Version 1.20.1 last revised October 2025 revealed [in part]: Encoding data: - For a comprehensive assessment (Admission, Annual, Significant Change in Status, and Significant Correction to Prior Comprehensive), encoding must occur within 7 days after the Care Plan Completion Date (V0200C2 + 7 days). -For a Quarterly, Significant Correction to Prior Quarterly, Discharge or PPS assessment, encoding must occur within 7 days after the MDS completion Date. Transmitting data: Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument, including the Care Area Assessment (CAA) Summary (Section V) and all tracking or correction information. Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements. Care plans are not required to be transmitted. Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 +14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days). Event ID: Facility ID: 455611 If continuation sheet Page 2 of 9 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 12/11/2025 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure assessments accurately reflected the health status for 2 of 14 residents (Residents #13 and #27) whose MDS assessments were reviewed, in that:1. Resident #13 had a physician order for insulin to be administered one time weekly on Monday per a sliding scale. Her MDS documented she received insulin injections daily.2. Resident #27 had a physician order for an antiplatelet medication. Her MDS assessments documented she received an anticoagulant medication. This failure placed residents at risk for not receiving care and services to meet their physical needs.The findings included: Review of the Resident #13's admission Record, dated 12/11/2025, documented a [AGE] year-old-female admitted to the facility on [DATE]. The record documented the resident's diagnoses included type 2 diabetes mellitus (a chronic condition when the body cannot use insulin properly resulting in high blood sugar levels). Review of Resident #13's Order Summary Report documented an order dated 1/22/2022 for NovoLIN R FlexPen ReliOn Solution Pen-injector 100 UNIT/ML (Insulin Regular Human) Inject subcutaneously one time a day every Monday for type 2 diabetes mellitus per sliding scale. Review of Resident #13's Medication Administration Record, dated August 2025, documented FSBS levels every Monday and documented no sliding scale Novolin insulin was administered. Review of Resident #13's Quarterly MDS assessment, dated 9/01/2025, documented the resident received insulin injections daily. Review of Resident #27's admission Record, dated 12/11/2025, documented a [AGE] year-old female admitted to the facility on [DATE] with a primary admitting diagnosis of atrial fibrillation (irregular heartbeat). Review of Resident #27's Order Summary Report documented an order dated 5/22/2025 for Clopidogrel 75 mg by mouth one time daily for atrial fibrillation (Plavix - antiplatelet medication). Review of Resident #27's Quarterly MDS assessment, dated 6/04/2025, documented the resident received an anticoagulant medication. In an interview on 12/11/2025 at 9:15 AM, the RN VPCO stated the facility did have a policy for completing MDS assessments and also followed the guidelines of the RAI manual. She stated the VPCR had been completing the residents' MDS assessments since the change in management companies on 11/19/2025. In an interview on 12/11/2025 at 9:17 AM, the DON stated the prior MDS Coordinator was a nurse who resided in another city and had completed the residents' MDS assessments remotely. During an interview and record reviews on 12/11/2025 at 5:05 PM, the VPCR stated she had started reviewing and completing MDS assessments for residents in the facility on 11/19/2025. She stated the Regional MDS Coordinator had been helping with the MDS assessments. The VPCR reviewed Resident #13's order for sliding scale Novolin insulin to be administered one time weekly on Monday, and reviewed the resident's MDS assessment dated [DATE]. She stated the insulin injection administered daily for 7 days was inaccurately documented on the MDS assessment. The VPCR reviewed Resident #27's order for Clopidogrel and the resident's MDS assessment dated [DATE]. She stated the Clopidogrel was an antiplatelet medication and had been inaccurately coded as an anticoagulant on the MDS assessment. The VPCR stated an expected negative outcome from MDS assessments not being accurately completed would be the inability to develop a care plan for the staff to accurately care for the residents. Review of the facility policy and procedure for Conducting an Accurate Resident Assessment, dated 2025, indicated the following [in part]: Policy:The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas.Definition: Accuracy of assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument (RAI) (i.e. Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455611 If continuation sheet Page 3 of 9 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 12/11/2025 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 0641 comprehensive, quarterly, significant change in status) . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455611 If continuation sheet Page 4 of 9 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 12/11/2025 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 Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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: 1. The wooden cabinet doors beneath the handwashing sink did not close completely. 2. The high-temperature dish machine did not work properly and was not being used. 3. The dietary staff were manually washing the resident use eating utensils, beverage glasses, coffee cups, the pots, pans, mixing bowls, cooking utensils and serving utensils in a two-compartment sink.4. The dietary staff did not document water temperatures and bleach sanitizer levels for the two-compartment sink.5. Floor tiles were missing beneath the high temperature dish machine.6. Wooden shelf units and cabinet had scraped surfaces and peeling paint with the porous wooden surfaces exposed and not sealed.7. Shelf liner was used to cover wooden shelves in the paper supply room and the shelves were soiled with food crumbs and dust beneath the shelf liner.8. Opened packages of dry foods were not stored in resealable bags or containers and were not labeled and dated when opened.9. The top exterior surface of the ice maker was soiled with a thick layer of dust build-up. The facility's failure placed residents at risk for foodborne illness, compromised nutritional health status, and being served food items that may not be fresh, taste stale, or be contaminated.The findings included: Observations and interviews on 12/09/25, between 9:45 AM and 10:10 AM, during the initial tour of the facility kitchen, revealed the following:- The liquid soap dispenser mounted on the wall near the hand washing sink; the dispenser was empty and a bottle with dish detergent was on the counter next to the sink to use for hand washing.- The wooden cabinet doors beneath the sink and counter did not close completely.- The Dietary Manager stated a new high temperature dish machine was delivered about 2 weeks ago and was installed. She stated the back two legs of the dish machine were removed by the Maintenance Director. The back of the dish machine was observed resting on wooden blocks. The Dietary Manager stated the dish machine was not a good fit in the space between the stainless steel counters. The Dietary Manager stated the dish machine was connected but it kept throwing the breaker when operated. She stated the dietary staff were told not to use it until an electrician could come to the facility and fix the breaker.- The Dietary Manager stated the residents were being served meals on paper (disposable) plates and bowls. She stated the residents were using the stainless steel silverware, beverage glasses, and coffee cups. She stated the dietary staff were using a two-compartment sink to wash the silverware, eating utensils, beverage glasses, coffee cups, pots, pans, serving utensils, and mixing bowls. The Dietary Manager stated detergent and bleach were added to the water in the first sink compartment and bleach was added to the water in the second sink compartment to sanitize. She stated there was not a sink used for clear rinse water. - The Dietary Manager stated she was not keeping a log of the two compartment sink water temperatures or bleach sanitizer level. - The floor tiles had been removed and were missing in the area beneath the dish machine and the concrete floor was exposed.- The wooden shelves and cabinets had scraped/peeling paint throughout the kitchen.- The paper supply closet had 9 wooden shelves covered with a thick textured shelf liner; the shelves were soiled with dust and food crumbs beneath the shelf liner; a plastic container with dry cereal, labeled as corn flakes was dated 9/02/25. The Dietary Manager stated the cereal was a staff member's and only 1 resident ate cold cereal and he had his own. - The wooden shelf unit on the wall to the left of the steam table had shelf liner covering the painted surface and contained inverted plastic bowls.- The old gas steamtable no longer worked and was located against the wall in the corner. The Dietary Manager stated she wished it would be removed. Observation and interview on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455611 If continuation sheet Page 5 of 9 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 12/11/2025 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 Residents Affected - Many 12/09/2025 at 10:12 AM, during observation of the Dietary Manager's office located in the East Hall in room [ROOM NUMBER], revealed the following: - The office was used for non-perishable food storage and contained a commercial refrigerator unit, and 2 wire rack shelf units which contained dry food items.- The shelves held an open bag with bread crumbs dated 8/29/25 that had been twisted to close, an open bag with small elbow macaroni that was not dated and had been knotted/tied to close, an open bag with small egg noodles dated 10/24/25 twisted to close, refried pinto beans in a resealable plastic bag that was not labeled and dated when opened, a 5 pound bag with white cake mix in a resealable bag dated 8/05. The Dietary Manager stated she hoped it was 2025 and not 2005. She stated she would throw the cake mix and pinto beans away.- A commercial refrigerator unit was against the wall behind the Dietary Manager's desk. The refrigerator was non-working and was used to store paper plates, cups, and plastic cup lids. The Dietary Manager stated she wished it would be removed from the room. Observation on 12/09/2025 at 10:28 AM revealed an ice maker in the hallway outside the door to the kitchen, located to the left of the nurse's station. The exterior top surface of the ice machine was soiled with a thick layer of dust. In an interview on 12/09/2025 at 11:30 AM, the DON stated she was the facility's Infection Preventionist. The ADON stated the residents had received influenza and pneumococcal vaccinations during September and October 2025. The ADON stated she would provide the infection control log for review. The ADON stated the facility had not had any outbreaks of any types of virus or infections, including respiratory or gastrointestinal. Record review of the facility's infection control tracking log indicated no infections related to gastrointestinal upset [nausea, vomiting, diarrhea] were documented during the months of November and December 2025. There was no documented evidence of indicators or symptoms of foodborne illness. During an observation and interview on 12/09/2025 at 3:18 PM, the Dietary Manager indicated the large tub purchased at the local hardware store. The label indicated a 27-gallon capacity. The tub was positioned on the stainless steel counter. The Dietary Manager provided a bottle with quaternary sanitizer. The label directed to use 1 ounce of sanitizer to 4 gallons of water. The recommended sanitizer level was 200 - 400 ppm. The Dietary Manager stated she mixed 1 ounce with 4 gallons of room temperature/faucet water. She measured the sanitizer/water solution with a test strip at a level of 200 ppm. The tub was observed to be large enough to hold rectangular sheet pans.[An online search for this product indicated the recommended water temperature was 75 degree F to 120 degrees F.] In an interview on 12/10/2025 at 1:20 PM, the Maintenance Director stated the electrician came to the facility after the lunch meal was served. He stated the electrician was going to replace the 20 amp breaker for the dish machine and he would go from there. In an interview on 12/11/2025 at 12:10 PM, the Dietary Manager stated the breaker for the dish machine had been changed yesterday (12/10/2025) but dish machine was still not running right and the staff were not using it. She stated the technician from the new chemical supply and service company would be at the facility next Monday or Tuesday (12/15/2025 or 12/16/2025) to work on the dish machine. The Dietary Manager stated the staff started using paper products the same day the new dish machine was installed, as it did not run right and tripped the breaker. She stated they used up the supply of paper products that was in storage and they bought paper products at the local grocery store until paper products could be ordered. [The new dish machine was installed 10/09/2025.] In an interview on 12/11/2025 at 5:49 PM, the VPCO stated a possible negative outcome from not having an operational dish washer and not utilizing a proper manual dishwashing procedure with a 3-compartment sink could be the spread of infection and possible foodborne illness. Review of the facility policy and procedure for Sanitation Inspection, dated 2025, indicated [in part]:Policy:It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455611 If continuation sheet Page 6 of 9 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 12/11/2025 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 Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations.Policy Explanation and Compliance Guidelines:1. All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects.Review of the facility policy and procedure for Manual Warewashing - 3 Compartment Sink, dated as reviewed/revised 12/11/2025, indicated [in part]:Policy:2. To prevent the spread of bacteria that may cause food borne illness, this facility washes, rinses, and sanitizes pots, pans, and other utensils using a 3 compartment sink in accordance with current standards for food safety. The Food and Drug Administration Food Code 2022 specified [in part]:Chapter 3 Food3-202.15 Package Integrity.FOOD packages shall be in good condition and protect the integrity of thecontents so that the FOOD is not exposed to ADULTERATION or potentialcontaminants. Chapter 4 Equipment, Utensils, and Linens4-602.13 Nonfood-Contact Surfaces.The presence of food debris or dirt on nonfood contact surfaces may provide a suitableenvironment for the growth of microorganisms which employees may inadvertentlytransfer to food. If these areas are not kept clean, they may also provide harborage forinsects, rodents, and other pests. Event ID: Facility ID: 455611 If continuation sheet Page 7 of 9 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 12/11/2025 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 0908 Keep all essential equipment working safely. 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 ensure the maintenance of mechanical and electrical equipment in safe operating condition in 1 of 1 kitchen, in that:The low temperature dish machine was not operating and was not being used to wash and sanitize the resident use eating utensils, beverage glasses, coffee cups, and the food preparation pots, pans, mixing bowls, cooking utensils, and serving utensils. This failure placed the residents at risk for foodborne illness and a decline in health status from being served food that had been prepared with pans and utensils that had not been properly sanitized. The findings included: Observation on 12/09/2025 at 9:50 AM revealed a high temperature dish machine was located in the facility kitchen. The manufacturer recommendations were for minimum water temperatures at 160 degrees F for washing and at 180 degrees F for rinsing. The dish machine was not in use at the time of the observation. In an interview on 12/09/2025 at 9:50 AM, the Dietary Manager stated a new high temperature dish machine was delivered about 2 weeks ago and was installed. She stated the back two legs of the dish machine were removed by the Maintenance Director. The back of the dish machine was observed resting on wooden blocks. The Dietary Manager stated the dish machine was not a good fit in the space between the stainless steel counters. The Dietary Manager stated the dish machine was connected but it kept throwing the breaker when operated. She stated the dietary staff were told not to use it until an electrician could come to the facility and fix the breaker. The Dietary Manager stated the residents were being served meals on paper (disposable) plates and bowls. She stated the residents were using the stainless steel silverware, beverage glasses, and coffee cups. She stated the dietary staff were using a two-compartment sink to wash the silverware, eating utensils, beverage glasses, coffee cups, pots, pans, serving utensils, and mixing bowls. The Dietary Manager stated detergent and bleach were added to the water in the first sink compartment and bleach was added to the water in the second sink compartment to sanitize. She stated there was not a sink used for clear rinse water. The Dietary Manager stated she was not keeping a log of the two compartment sink water temperatures or bleach sanitizer level. In an interview on 12/09/2025 at 1:46 PM, the facility Maintenance Director stated he had worked in this facility for the past 11 years. He stated the new management company took over on 12/01/2025. The Maintenance Director stated the old dish machine went out during September or October 2025. He stated the pump for the chemicals went out and they could not get parts for it. He stated the Executive from the facility's prior management company got the new dish machine. The Maintenance Director stated he did not know where the Executive got it or where it came from. He stated it was delivered during mid-November. The Maintenance Director stated it was new and wrapped in plastic. He stated the Maintenance Director from the prior sister facility in located in another town came and together they took the new dish machine out of the box and put it together and installed it in the kitchen. He stated they could not program it. The Maintenance Director stated the new dish machine tripped the breaker every time it was used. He stated the back legs had been removed and placed on wooden blocks in an attempt to move the dish machine back closer to the wall. He stated the plumbing was on the outside of the walls and the drain line ran along the base of the wall and prevented the dish machine from being pushed back closer to the wall. The Maintenance Director stated the facility would have a new chemical supply and service company for the dish machine, laundry, and housekeeping. He stated technician from the new chemical supply and service company would be able to program the dish machine and to determine the voltage for the machine to make recommendations to an electrician and plumber. He stated the facility's new management company was working on the contract with the chemical supply and service company. The Maintenance Director stated there had not been any Residents Affected - Many (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455611 If continuation sheet Page 8 of 9 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 12/11/2025 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete viruses or bugs that moved through the facility residents - no diarrhea, no vomiting. In an interview and observation on 12/09/2025 at 2:29 PM, the Dietary Manager stated she was not present when the new dish machine was installed. The Dietary Manager stated the new dish machine kept throwing the breaker and she was told not to use it. The Dietary Manager inquired if a large bin could be used as a third compartment to fill with water and quaternary sanitizer. She stated she had quaternary sanitizer and the test strips for it and stated the test strips were delivered with the food order today. The Dietary Manager stated quaternary sanitizer did not have to be used in hot water, it could be in cool water. In an interview on 12/09/2025 at 3:10 PM, the Maintenance Director stated an electrician would be at the facility in the morning and would assess whether the breaker was bad or if the entire breaker box needed to be replaced. He stated the kitchen had its own breaker box, located on the wall between the refrigerator and freezer units. The Maintenance Director stated the new chemical supply and service company was contacted and they said the dish machine was good and to have the electrician evaluate the voltage on the breaker box. In an interview on 12/10/2025 at 1:20 PM, the Maintenance Director stated the electrician came to the facility after the lunch meal was served. He stated the electrician was going to replace the 20 amp breaker for the dish machine and they would go from there. During an interview and record review on 12/10/2025 at 1:50 PM, the Business Office Manager provided copies of printed email messages regarding the order for the dish machine. The email message dated 9/26/2025 documented the order was from a restaurant supply vendor and would be delivered by freight shipment. The Business Office Manager wrote a notation on the copy of the email that documented the dish machine was delivered to the facility on [DATE]. The Business Office Manager showed a text message saved on her cell phone from the Maintenance Director from a sister facility who had come to the facility to assist the Maintenance Director with installing the new dish machine. The text message from the Maintenance Director to the Business Office Manager was dated 10/09/2025 and specified they had wired the dish washer machine. The Business Office Manager stated the dish machine was installed 10/09/2025, the day after it was delivered. In an interview on 12/11/2025 at 5:49 PM, the VPCO stated a possible negative outcome from not having an operational dish washer and not utilizing a proper manual dishwashing procedure with a 3-compartment sink could be the spread of infection and possible foodborne illness. Review of the facility's policy and procedure for Mechanical Cleaning and Sanitizing of Utensils and Portable Equipment, dated 10/01/2018, indicated [in part]: Policy: The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for mechanical cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards.Procedure:1. Use only an approved dish machine that is properly installed and maintained. Operate the dish machine as instructed in the manufacturer's directions. Schedule and complete regular maintenance inspections. Event ID: Facility ID: 455611 If continuation sheet Page 9 of 9