Inspection·March 8, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #1's Nursing Progress Note, dated [DATE] at 10:48 AM revealed LVN A documented the resident's physician was called at 10:33 AM and he stated to monitor the resident's BP and monitor the resident closely. The LVN documented she went to check the resident's BP at 11:15 AM in the dining room and found the resident unresponsive. The LVN got the DON. The resident was laid on the floor and oxygen was applied. The DON did sternal rubs and 911 was called. The resident left with EMS. The physician and family were notified. Review of the Medication Incident Report, dated [DATE] revealed the DON documented Resident #1 was given the wrong medication by LVN A, who immediately reported she had given Resident #1 another resident's medications by mistake. The resident's physician was called at 10:33 AM and informed Resident #1 received anti-hypertensives and a narcotic. Orders were received to monitor the resident's BP and monitor her closely. At approximately 11:15 AM, LVN A reported Resident #1 was unconscious and non-verbal. The DON found Resident #1 unconscious in the dining area and gave her a sternal rub and called her name in a loud voice. The DON listened to her heart and lung sounds and none were noted. Resident #1 was placed on a mat on the floor, oxygen was applied, and 911 was called. The DON continued sternal rubs and called the resident's name. EMS arrived just as Resident #1 stated she was awake and could hear the DON. The DON assisted EMS with putting Resident #1 onto the gurney. The physician was called at 11:24 AM and was notified Resident #1 was transported to the local hospital. The family was notified by LVN A and LVN B. The DON documented the resident had been alert and oriented that morning. In an interview on [DATE] at 2:18 PM, the DON stated LVN A was a new nurse and was hired within the last year. The DON did not document any notes regarding the incident. The DON stated the Regional Nurse Consultant told her to verbally counsel LVN A, but not to give her a written disciplinary notice. In an interview on [DATE] at 3:11 PM, the Administrator stated she had wanted to report the incident of Resident #1 receiving the wrong medications to the State regulatory agency. She stated it was an avoidable incident. The Administrator stated Resident #1 received 7 medications that were not ordered for her and she could have died. She stated the corporate Regional Nurse Consultant had told the DON to counsel LVN A because she was so upset, she was a young nurse, and everyone made mistakes. The Administrator stated she spoke with her corporate boss and he told her the incident was not reportable. Review of the facility's Abuse Prevention Program and Reporting Policy - Risk Management, dated as revised 11/2022 revealed the following [in part]: Incidents that a NF Must Report to HHSC and the Time Frames for Reporting. A NF must report to HHSC the following types of incidents, in accordance with applicable state and federal requirements: Abuse Neglect Exploitation Death due to unusual circumstances (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 2 of 11 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 455893 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Care Center of Henrietta 807 W Bois D Arc Henrietta, TX 76365 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 A missing resident Level of Harm - Minimal harm or potential for actual harm Misappropriation Drug theft Residents Affected - Few Suspicious injuries of unknown sources Fire Emergency situations that pose a threat to resident health and safety The following table describes required reporting timeframes for each incident type: Type of Incident When to Report Abuse (with or without serious bodily injury); or Neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, that result in serious bodily injury. Immediately, but not later than two hours after the incident occurs or is suspected FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 3 of 11 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 455893 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Care Center of Henrietta 807 W Bois D Arc Henrietta, TX 76365 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 7 residents (Resident #1) reviewed for medication regimen, in that: Residents Affected - Few Resident #1 was administered the morning medications for another resident, which included three different blood pressure medications, a narcotic medication, and a diuretic medication on 2/29/2024 at approximately 10:20 AM. Resident #1 became unresponsive on 2/29/2024 at 11:15 AM and was transported by ambulance to the local hospital emergency room. Resident #1 was admitted to the hospital on [DATE] with a diagnosis of hypotension (abnormally low blood pressure) due to drugs. An Immediate Jeopardy was identified on 03/07/2024. The Immediate Jeopardy Template was provided to the Administrator on 03/07/2024 at 5:15 PM. While the Immediate Jeopardy was removed on 03/08/2024 at 6:55 PM, the facility remained out of compliance at a scope of isolated and severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective actions. This failure placed residents at risk of significant medication errors and a decline in health status, serious injury, and/or death. The findings included: Review of Resident #1's admission Record, dated 3/01/2024, revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident had an Out of Hospital DNR Code Status. The resident's diagnoses included sepsis (infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever), pneumonia, urinary tract infection, congestive heart failure (the heart's main pumping chamber - left ventricle - becomes stiff and unable to fill properly), hypertension (high blood pressure), dementia (impaired brain function and thought processes), and hypothyroidism (thyroid disorder). Review of Resident #1's comprehensive care plan, dated 2/28/2024 revealed it addressed hypertension related to congestive heart failure. The care plan approaches included to give anti-hypertensive medications at ordered and monitor for side effects such as orthostatic hypotension and increased heart rate. Review of Resident #1's Medication Administration Record, dated February 2024, revealed LVN A documented a blood pressure of 121/75 on the morning of 2/29/2024. The record documented Resident #1's medication orders included: Cozaar 50 mg daily (anti-hypertensive medication) Metoprolol succinate 12.5 mg daily (anti-hypertensive medication) Furosemide 10 mg daily (diuretic medication) Tramadol 50 mg daily at bedtime for pain (opioid pain relief medication). Review of the Medication Incident Report, dated 2/29/2024 revealed the DON documented Resident #1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 4 of 11 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 455893 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Care Center of Henrietta 807 W Bois D Arc Henrietta, TX 76365 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few was given the wrong medication by LVN A, who immediately reported she had given Resident #1 another resident's medications by mistake. The resident's physician was called at 10:33 AM and informed Resident #1 received anti-hypertensives and a narcotic. Orders were received to monitor the resident's BP and monitor her closely. At approximately 11:15 AM, LVN A reported Resident #1 was unconscious and non-verbal. The DON found Resident #1 unconscious in the dining area and gave her a sternal rub and called her name in a loud voice. The DON listened to her heart and lung sounds and none were noted. Resident #1 was placed on a mat on the floor, oxygen was applied, and 911 was called. The DON continued sternal rubs and called the resident's name. EMS arrived just as Resident #1 stated she was awake and could hear the DON. The DON assisted EMS with putting Resident #1 onto the gurney. The physician was called at 11:24 AM and was notified Resident #1 was transported to the local hospital. The family was notified by LVN A and LVN B. The DON documented the resident had been alert and oriented that morning. Review of Resident #1's Nursing Progress Note, dated 2/29/2024 at 10:33 AM revealed LVN A documented the resident's family and physician were contacted about the wrong medication being given. Review of Resident #1's Nursing Progress Note, dated 2/29/2024 at 10:48 AM revealed LVN A documented the resident's physician was called at 10:33 AM and he stated to monitor the resident's BP and monitor the resident closely. The LVN documented she went to check the resident's BP at 11:15 AM in the dining room and found the resident unresponsive. The LVN got the DON. The resident was laid on the floor and oxygen was applied. The DON did sternal rubs and 911 was called. The resident left with EMS. The physician and family were notified. Review of Resident #1's hospital medical record, dated 2/29/2024, revealed the following [in part]: History of Present Illness Patient was given another resident's medications that included: Amlodipine 10 mg (blood pressure lowering - calcium channel blocker) Carvedilol 25 mg (blood pressure lowering - alpha-beta blocker) Isosorbide mononitrate ER (extended release) 60 mg (nitrate - blood vessel widening, preventative for chest pain) Norco 7.5 mg (Hydrocodone - opioid for pain relief) Spironolactone 25 mg (diuretic - fluid reduction) She then went unresponsive with no pulse and no breaths. By the time EMS arrives she was breathing on her own and had a pulse. She was found to be hypotensive and brought in. Clinical Impression Hypotension due to drugs. Chronic anemia associated with chronic disease. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 5 of 11 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 455893 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Care Center of Henrietta 807 W Bois D Arc Henrietta, TX 76365 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 0760 Triage: 2/29/24 at 11:20 AM - BP 59/24. Level of Harm - Immediate jeopardy to resident health or safety In an interview on 3/01//2024 at 2:18 PM, the DON stated LVN A had made a medication error the prior day on 2/29/2024. She stated LVN A got distracted when someone was talking to her and she grabbed the wrong medication cup and gave Resident #1 the medications for another resident. She stated the medications included a blood pressure pill and Norco. The DON stated LVN A immediately told her at 10:30 AM. She stated LVN A realized what she had done when she did it. The DON stated she called Resident #1's physician at 10:33 AM, and he asked what BP medication Resident #1 had been given, which was Isosorbide 60 mg. The physician stated that was a high amount of blood pressure medication for her and to monitor her BP. The DON stated at 11:15 AM, Resident #1 was unresponsive, had no heartbeat or pulse, and oxygen was applied. The DON stated she did a sternum rub and someone called 911. The DON stated she called the physician at 11:24 AM and notified him Resident #1 was awake, alert, and on her way to the ER. The DON stated she had LVN A call and notify the resident's family. The DON stated the ADON accompanied LVN A on her next medication pass. The DON stated she completed an incident report for the med error. The DON stated LVN A was a new nurse and was hired within the last year. Residents Affected - Few In an interview on 3/01/2024 at 3:40 PM, the ADON stated she had made random observations of LVN A during the past few months and there was never anything observed that gave her reason for alarm or concern. The ADON stated she did not know when the medications were being given yesterday morning or if LVN A was passing medications from the medication cart or from the medication room. The ADON stated LVN A told her what happened. LVN A was asked if she had passed any more medications since the incident and she said no. The ADON stated she went through LVN A's next medication pass with her about noon on 2/29/2024. She stated LVN A passed medications from the medication room (carried the medication cup from the medication room rather than pushing the medication cart) due to not having a full medication pass at that time. The ADON stated she observed LVN A through the whole process from start to finish. She stated she observed LVN A review the resident's medication order, open the medication cart and find the correct medication, verify the labeled medication card with the order, pop the medication from the bubble pack card into the medication cup, and take it to the resident and verify, and administered the medication. LVN A initialed the resident's electronic MAR after the medication was administered. The ADON stated the incident with Resident #1 was the only medication error that has been made since she started employment in the facility during November 2023. The ADON stated LVN A was the youngest and newest nurse, and the other licensed nurses have had more experience. The ADON stated she thought LVN A was competent and she made a mistake when she got busy. She stated LVN A needed to slow down and think about what she was doing. The ADON stated the standard of practice was to pop medications from the cards for one resident at a time. In an interview on 3/01/2024 at 4:43 PM, LVN A stated when she arrived at work on the morning 2/29/2024, the computer for the medication cart had not been charged and she had it plugged it into the outlet in the medication room. She stated she had taken a resident's vital signs and blood pressure and had placed his medications in a cup on top of the medication cart in the medication room. She stated she gathered her equipment to take Resident #1's vital signs (BP cuff, thermometer, oxygen pulse oximeter) and carried the medication cup and equipment to Resident #1 who was in the sunroom. LVN A stated she had it in her head to give Resident #1 the medications and she gave them to her and then took her vital signs. She stated it was about 10:20 AM. She stated she then went back to the medication room to enter the medications were given on the MAR when she realized what she had done. LVN A stated she immediately reported her error to the DON. Resident #1 was assessed and was later found to be unresponsive. The DON called the doctor. LVN A stated she called the family and said Resident #1 had been given the wrong medications and was on the way to the hospital. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 6 of 11 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 455893 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Care Center of Henrietta 807 W Bois D Arc Henrietta, TX 76365 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few stated the BP medication given was Isosorbide. LVN stated she felt awful about it and became tearful. She stated she would focus on the process of start to finish for one resident at a time. LVN A demonstrated how she reviewed a medication order in the electronic MAR, unlocked the medication cart and to find the medication and compared the card to the order in the computer, signed out the medication in the narcotic book if applicable, popped the medication from the card into a medication cup, replaced the medication card in the cart and locked it, gave the medication to the resident, and then returned and documented Y in the electronic MAR. LVN A stated she learned from this error and would focus and think about what she was doing. Observation and interview on 3/04/2024 at 1:45 PM with Resident #1 in the hospital revealed she was laying on her back in bed with the head of the bed elevated. She was using supplemental oxygen via nasal cannula. Resident #1 was awake, alert, and oriented. Resident #1 stated her doctor had been to the hospital to see her. Resident #1 stated she was feeling some better. She stated she had gone to the nursing facility after being in the hospital with pneumonia. Resident #1 stated she found out what had happened to her at the nursing home and stated she did not receive good care there. Resident #1 stated she planned to go to a different nursing home where her family members had both been and she had visited them. She stated she was familiar with the place. Resident #1 stated she could not walk very well anymore and hoped to receive therapy there. Resident #1 stated she took Tramadol and it helped with her hip and leg pain. She stated she had a wheelchair and a power chair and hoped to be able to use it again. In an interview on 3/05/2024 at 1:24 PM, the DON stated the ADON had observed LVN A give the entire lunch medication pass on Hall 2 and Hall 3 on 2/29/2024. She stated she did verbal counseling with LVN A on Thursday, 2/29/2024. The DON stated on Saturday, 3/02/2024 she came to the facility and did an in-service training on the medication administration policy and procedure with LVN A and gave her a suspension notice pending investigation. The DON stated the Administrator determined LVN A may need more training and needed to be taken off the schedule. The DON stated she came to the facility on Saturday and suspended LVN A's employment per the Administrator's directive. She stated the Administrator spoke with her corporate boss on 3/04/24 and he gave instruction for LVN A to have additional instruction for the medication pass with the medication pass checklist to be completed for 3 days - Thursday, Friday and Saturday. The DON stated LVN A was scheduled to return to work on Thursday 3/07/24 and the ADON would go with her during the medication pass with a checklist. The DON stated this was the first medication error LVN A had made since she started employment during November 2023. In a telephone interview on 3/06/2024 at 12:51 PM, Resident #1's physician stated he was aware of the incident and had been called immediately by a nurse at the facility. The physician stated he had been at the facility the morning of Thursday 2/29/24 before the incident. He stated Resident #1 was fine and was going to therapy. The physician stated Resident #1 became syncopal after being given the other resident's blood pressure medications. He stated she was responsive when the ambulance crew arrived to transport her to the ER. The physician stated the safety concern for Resident #1 was her blood pressure going too low and making her pass out. He stated the other medications did not have huge concerns (pain and diuretic medications). He stated the BP medications were the main concern. Review of the facility's policy and procedure for Medication Administration, dated 1/2013 revealed the following [in part]: Purpose: To administer the following according to the principles of medication administration, including the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 7 of 11 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 455893 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Care Center of Henrietta 807 W Bois D Arc Henrietta, TX 76365 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 0760 right medication, to the right resident/patient at the right time, and in the right dose and route. Level of Harm - Immediate jeopardy to resident health or safety Equipment: Residents Affected - Few Administration supplies as indicated Medication as ordered Procedure: 1. Verify physician's orders for medications to be administered. 2. Review any special precautions and perform needed evaluations prior to administering medication to the resident/patient. Review resident/patient allergies. Review pertinent lab results, as indicated . Perform needed evaluations prior to administering specific medications (e.g., pulse, blood pressure, blood glucose). 3. Identify resident/patient via wristband or picture ID. 4. Explain the procedure to the resident/patient. Include the type of medication ordered, the reason, frequency, and route . 10. Read the Medication Administration Record (MAR) for the ordered medication, dose, route, and time . 13. Verify the following, again, by comparing medication to MAR prior to administering: Correct resident/patient Correct medication Expiration date Dose and dosage form Route Time . This was determined to be an Immediate Jeopardy on 3/07/2024. The Administrator was provided the Immediate Jeopardy Template on 3/07/2024 at 5:15 PM and a Plan of Removal was requested. The following Plan of Removal submitted by the facility and accepted on 3/08/2024 at 4:37 PM: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 8 of 11 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 455893 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Care Center of Henrietta 807 W Bois D Arc Henrietta, TX 76365 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 1. Resident #1 was immediately assessed by the Licensed Nurse (LN) on 02/29/24 and the physician was notified of the medication error with a new order to monitor the resident's blood pressure closely. The order was noted by the LN. When the LN went to monitor Resident #1 after receiving the order, the resident was found unresponsive. The LN called EMS which responded quickly, and the resident was discharged to the ER for observation on 02/29/24. 2. The 24-hour report was reviewed on 3/7/24 by the Assistant Director of Nursing (ADON) for the past 72 hours to ensure there were no further medication errors and/or changes in any resident's condition. Any concerns will be addressed by a LN if identified. The results of the report covering the past 72 hours found no additional medication errors or changes in residents' condition. No further physician notification of actions by the licensed nurse was necessary. 3. When the Director of Nursing (DON) interviewed the LN on 02/29/24 who made medication error, it was determined that the LN dispensed the medication for a resident other than resident #1. She then realized that she needed to take resident #1's blood pressure, and subsequently also gave the other resident's medication to resident #1. The education provided to this LN by the DON included avoiding distractions and completing the medication pass one resident at a time once starting the medication administration process. Beginning 3/6/24, LNs and Certified Medication Aides (CMAs) will have a medication pass observation completed by a Registered Nurse (RN) prior to the beginning of their next shift and receive education as needed for any concerns identified by the RN conducting the observation. The RN will observe a minimum of 50% of the LNs or CMAs medication pass for that scheduled time to validate competency. The RN will stop the LN or CMA if they identify a problem and provide immediate reeducation in real time on the issue identified. The medication administration observations will be documented on the facility's Medication Administration/Technique Observation tool which follows the facility's Medication Management policy. On 3/8/24, the LNs and CMAs went through additional medication administration education that was provided by the ADON. This education included avoiding distractions to the medication pass and once starting to dispense medication for a resident, not to stop and perform any other non-emergent tasks. It also included following the facilities procedure on Medication Administration from the facilities Nursing Procedure Manual. The LNs and CMAs understanding of the education will be demonstrated through RN observed medication administration observations previously described. All newly hired LNs and CMAs will go through medication pass validations by a LN with the tools mentioned above during their orientation. 4. The DON, ADON or designee will complete med pass observations weekly for 12 weeks to ensure licensed nurse and medications aides continue to administer medications per physician's orders and to the right resident. The Medical Director was notified of this survey outcome on 3/8/24 and will be involved in the facility QAPI process surrounding this plan. A report of the medication administration audits will be submitted to the QAPI committee for review and recommendations as needed. The facility held an initial QAPI meeting on 3/8/24 to review the outcome of the medication administration observations to this point. Starting the week of March 11, 2024, a QAPI meeting will be conducted weekly for 4 weeks then monthly. The DON is responsible for monitoring and additional actions to this plan if needed. Date of Compliance: 03/08/24 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 9 of 11 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 455893 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Care Center of Henrietta 807 W Bois D Arc Henrietta, TX 76365 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 0760 Monitoring and verification of the facility's Plan of Removal began on 3/08/2024 at 4:40 PM as follows: Level of Harm - Immediate jeopardy to resident health or safety Observation on 3/06/2024 at 11:46 AM revealed the DON was observing LVN C passing medications and was using a medication administration competency checklist. Residents Affected - Few In an interview on 3/06/2024 at 11:52 AM, the DON stated she did medication administration competency checklist for LVN C. She stated the MDS Coordinator had observed LVN D and did the medication competency on her. The DON stated they were the only 2 LVNs at the facility. She stated 6 more LVNs would be evaluated for medication administration competency. The DON stated LVN A would have 3 days of evaluation using the medication checklists. She stated tomorrow and Friday (3/07/24 and 3/08/24) the ADON would observe LVN A and complete the medication administration checklist and on Saturday, 3/09/24 the weekend RN would observe LVN A and complete the medication administration checklist. In an interview on 3/07/2024 at 2:32 PM, the MDS Coordinator stated she had evaluated LVN D and completed the medication checklist with her yesterday on 3/06/2024. During an observation and interview on 3/07/2024 at 4:03 PM, MA E was observed during the preparation of medication to administer to a resident. She stated she would not take the medication cart down the hallway, due to only having medication for 1 resident. MA E reviewed the resident's medication orders in the electronic medication administration record, unlocked the medication cart and located the medication card, popped the medication into a medication cup, returned the medication card to the cart, and locked the medication cart. She proceeded to walk down the hallway to the resident's room carrying the medication cup and a glass with water, and stated she identified the resident by her picture on the medication administration record and by her room number. MA E identified herself to the resident, explained the pills she had brought for the resident, tapped the pills from the medication cup into the resident's mouth, and offered her the glass of water. MA E left the resident's room and walked back to the medication cart, pulled up the resident's medication administration record, initialed the medication had been given, and closed the electronic medication administration record. During an observation and interview on 3/07/2024 at 4:40 PM, LVN B was observed during the preparation of medication to administer to a resident who was seated at a table in the dining room. The LVN pushed the medication cart from the medication room and positioned the cart against the wall to the right of the entrance to the dining room. LVN B stated she took the medication cart into the halls when she had the main medication pass, but sometimes just carried the medication cup and a glass of water to the resident if it was only one resident. LVN B reviewed the medication order in the resident's electronic medication administration record. The resident's picture was in the upper left-hand corner of the medication administration record. LVN B unlocked the medication cart, found the medication card and compared it to the order on the medication administration record. She popped one tablet from the medication card into a medication cup, returned the medication card into the medication cart, and locked the cart. LVN B hit the screen saver on the computer, took the medication cup and a glass of water to the resident and watched her swallow the medication. She returned to the medication cart and entered the medication administered on electronic medication administration record and closed the record. In an interview on 3/08/2024 at 11:02 AM the ADON stated she was accompanying LVN A during the medication passes for the day. Review of the fax cover sheet dated 3/08/2024 at 1:41 PM revealed the Administrator had sent the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 10 of 11 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 455893 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Care Center of Henrietta 807 W Bois D Arc Henrietta, TX 76365 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Medical Director a notification letter regarding the medication error, a copy of the IJ Template and the facility's draft Plan of Removal. Review of the in-service training record dated 3/08/2024 at 2:00 PM revealed a training was provided to the licensed nurses regarding the topic of medication management and the facility's policy and procedure for medication error preventing and reporting. The attendance sheet was signed by a medication aide, 5 LVNs, and the weekend RN. In an interview on 3/08/2024 at 5:37 PM, LVN B stated the ADON had watched her pass medications yesterday on 3/07/2024. LVN B stated the nurses had in-service training that day at 2:00 PM and the topics covered were medication errors, the types of medication errors - giving the wrong medication or transcription errors in orders, using the 5 Rights of Medication administration, and avoiding distractions when preparing medications for administration. Observation on 3/08/2024 at 5:48 PM revealed the ADON was accompanying LVN A on the medication pass in Hall 2. The medication cart was in the hallway. Review of the QAPI Meeting Sign-in Sheet, dated 3/08/2024 at 3:00 PM, revealed the committee discussed the IJ Plan of Removal for medication error. During an interview and record review on 3/08/2024 at 4:26 PM, the ADON provided a copy of the 72 Hour Summary report dated 3/04/24 - 3/07/24. She stated the 24-hour report was printed from the program used for the residents' electronic health records and included new orders, progress notes, weights and vital signs. She stated there was not a way to filter all the information that was included in the report. The ADON stated the MDS Coordinator reviewed the 24-hour report in the morning, Monday through Friday, and she sent an email to the Administrator, DON, ADON, and therapy staff with any concerns or anything that needed follow-up. Review of the copy of the 72 Hour Summary report revealed it consisted of 32 pages and the first page had been signed as reviewed by the ADON on 3/07/24 at 1900 (7 PM). The 72 Hour Summary report had 10 hand-written documented notations for vital signs and weight changes that had been rechecked. [This interview and record review were conducted prior to the acceptance of the final draft of the Plan of Removal.] The Administrator was informed the Immediate Jeopardy was removed on 3/08/24 at 6:55 PM. The facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 11 of 11