Inspection·May 1, 2024

F 0550 catheter drainage bag. Level of Harm - Minimal harm or potential for actual harm In an observation and interview on 04/28/2024 at 10:51 AM with Resident #16 revealed a catheter bag hanging from the Resident #16's chair without a privacy bag. The resident's door was open, and the bag was viewable from the hall. He stated that they forget to cover it and that he did not want to make a fuss about it. He stated he would like it covered and that he had a bag to cover it, it was just not on it. Residents Affected - Few In an observation on 04/29/2024 at 2:30 PM of Resident #16 revealed a catheter bag hanging from the Resident #16's chair without a privacy bag. The resident's door was open, and the bag was viewable from the hall. In an interview on 04/29/2024 at 3:00 PM the LVN A revealed that she was not sure why the Resident #16's catheter bag was not covered. She said that she knew it should be covered and she would talk to her DON about it. In an interview on 04/30/2024 at 9:45 AM the DON said that the catheter bag should always be covered with a privacy bag if it was care planned and that Resident #16's care plan stated to have a privacy bag covering the catheter bag. She stated that the failure could place residents at risk for dignity issues if it is not covered. In an interview on 04/30/2024 at 9:50 AM with the DON, a copy of the facilities policy and procedures covering dignity and catheter bag covers was requested and was not received at the time of exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 2 of 31 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 05/01/2024 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 0583 Keep residents' personal and medical records private and confidential. 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 personal privacy by securing signed consents for the use of security cameras for 1 of 2 (Resident #28) residents reviewed for privacy. Residents Affected - Few The facility had operational security cameras in a resident's room without obtaining consents from the resident who occupied the room. This failure could place residents at risk of embarrassment, and reduction of the self-esteem and self-worth by not being provided desired privacy during personal care or meetings with family or physicians. Findings included: Record review of Resident #28''s face sheet dated 05/01/2024, revealed that she was [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included the following: bipolar with psychotic features (episodes of mood swings ranging from depressive lows to manic highs with disconnection from reality), Depressive episodes (periods of feeling low), and venous insufficiency (improper functioning of the vein valves in the legs). Record review of Resident #28's Quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 09 indicating moderate cognitive impairment. Section GG revealed her Activities of Daily Living were coded as Independent. Record review of Resident #28's Care Plan dated 03/05/2024 revealed there was no documentation for Authorized Electronic Monitoring. Record review of Resident #28's Clinical Records from 08/28/2023 to 05/01/2024 revealed there was no documentation of a signed consent for Authorized Electronic Monitoring by Resident #28. In an interview and observation on 04/28/2024 at 11:08 AM, Resident #28 was sitting in her room watching a TV in her recliner while wearing a bathrobe to cover her body, she stated it was for privacy. She pointed out the camera that was not pointed at her bed, but that was pointed towards the other side of her room, which was not occupied. She stated she did not want it. She said it was from the elderly lady that was here, but she had been gone awhile. She was wanting the camera out and to have her own privacy. There was not a sign placed in the room or outside of the resident's room that reflected or alerted that the resident's room was being electronically monitored. In an interview on 05/01/2024 at 11:25 AM, the DON revealed that the camera that was placed in Resident #28's room was a facility camera that was originally placed for the resident that was in the room prior to her, she was unsure when that resident left or who it was. She stated that they must have forgotten to remove the camera. She stated that she did not realize the resident had not agreed or consented to place the camera in the room. She said the camera could only be viewed from the nurse's station and it was not being recorded, it was only a live feed. She stated that having the camera without proper consent was a privacy issue. Record review of the policy and procedure, titled; Authorized Electronic Monitoring dated December 2018, revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 3 of 31 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 (X3) DATE SURVEY COMPLETED A. Building 05/01/2024 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 0583 Policy Interpretation and implementation: Level of Harm - Minimal harm or potential for actual harm 1) Residents Affected - Few the resident, resident representative, or legal representative is to complete the request for authorized electronic monitoring form. 2) If the resident has a roommate, consent must be obtained, using the consent to authorize electronic monitoring form. 3) Anyone conducting AEM must post and maintain a conspicuous notice at the entrance of the residence room period the notice must state that electronic monitoring device is in use. 4) If I convert electronic monitoring device is discovered by facility, the resident, the resident's representative, or legal representation must meet all requirements for a EM before monitoring can continue. 5) Prior to installation the AEM device must be approved by the executive director. The electronic monitoring device is video only and cannot include audio recording, two-way audio, microphone, or interactive audio components. The facility used the DADS Form 0065 as part of their policy. The form was dated November 2004 (Form 0065 Texas Department of Aging and Disability Services) revealed the following: Information Regarding Authorized Electronic Monitoring for Nursing Facilities A resident's guardian or legal representative is entitled to conduct authorized electronic monitoring (AEM) under subchapter R, Chapter 242, Health and Safety Code. To request AEM, you, your guardian or legal representative must: 1. Complete the Request for Authorized Electronic Monitoring form. 2. Obtain the consent of other residents, if any, in your room, using the Consent to Authorized Electronic Monitoring form and 3. Give the form(s) to the facility administrator or designee. Record review of the Consent by Roommate form 0067 for Authorized Electronic Monitoring, Texas Department of Aging and Disability dated January 2015-E revealed it was to be signed by roommates of residents with authorized electronic monitoring. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 4 of 31 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 05/01/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services for 1 of 2 residents (Resident #16) reviewed for urinary catheters in that: The facility failed to ensure that Resident #16's urinary catheter type and size was documented in the Physician order. The facility failed to ensure Resident #16's urinary catheter was irrigated as ordered. The facility failed to ensure Resident #16's urinary catheter care, every shift as ordered was completed. The facility failed to ensure Resident #16's urinary catheter output every shift as ordered was completed. This deficient practice could affect residents who had urinary catheters and could result in trauma or urinary tract infections. Findings included: Record review of Resident #16's electronic Face Sheet dated 05/01/2024 revealed he was a [AGE] year-old male that was re-admitted to the facility on [DATE] with a diagnosis that included neuromuscular dysfunction of the bladder (unable to control bladder due to nerve damage), and prostatic hyperplasia with lower urinary tract symptoms (enlarged prostate, which includes frequent urination, weak urine stream and inability to urinate). Record review of Resident #16's Quarterly MDS dated [DATE] revealed the following: *Section C- Cognitive Patterns revealed a BIMS score of 10 (moderate cognitive impairment). *Section H-Indwelling Catheter revealed that the resident does have an indwelling catheter. Record review of Resident #16's Comprehensive Care plan dated 02/09/2024 revealed the following: Focus: Resident #16 has long term indwelling Foley catheter: neurogenic bladder, history of long-term catheter use, and ongoing follow up by your urologist. Goal: resident #16 will remain free from catheter related trauma through review date. Interventions/Tasks: Resident #16 has a Foley catheter. Position catheter bag and tubing below the level of the bladder and away from the entrance room door. Foley catheter's privacy bag to Foley catheter drainage bag. Record review of Resident #16's physician's electronic consolidated orders for April 2024 revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 5 of 31 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 05/01/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some -Catheter care every shift with soap and water. Access Foley catheter for proper function and ensure proper placement of catheter bag every shift for Foley catheter care every shift related to urinary tract infection, site not specific. Check for proper function in proper placement of tubing and bag. To be completed on ordered times of 6:00 AM, 2:00 PM, and 8:00 PM, ordered 08/20/2023. -Change Foley catheter tubing bag every month on the 10th and PRN for malfunction dislodgment. Document in nursing notes catheter change every night shift starting on the 10th and ending on the 10th of every month, ordered 08/20/2023. -Irrigate Foley catheter with 30 milliliters of normal saline irrigation, every week and period every evening shift every Thursday at ordered times of 6:00 AM, 2:00 PM and 8:00 PM, ordered 08/20/2023. -Foley catheter output every shift, document amount, urine observation to include color and sediment, ordered times of 6:00 AM, 2:00 PM, and 8:00 PM, ordered 08/20/2023. Record review of Resident #16's April 2024 TAR revealed the following orders: -To change foley catheter bag and tubing every month on the 10th. Document in Nursing Notes. Documentation in Nursing Notes was never on April 10, 2024. -Urinary catheter as ordered weekly on Thursday's evening shift was not irrigated on Thursday April 18, 2024's evening shift. -Urinary catheter care, every shift at 6:00 AM, 2:00 PM and 8:00PM, was not completed as ordered on the following dates and times: April 3, 2024, at 2:00 PM April 19, 2024, at 2:00 PM April 30, 2024, at 6:00 AM April 1, 2024, at 2:00 PM April 3, 2024, at 2:00 PM April 5, 2024, at 6:00 AM and 2:00 PM April 9, 2024, at 6:00 AM April 10, 2024, at 2:00 PM April 12, 2024, at 2:00 PM April 13, 2024, at 6:00 AM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 6 of 31 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 05/01/2024 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 0690 April 14, 2024, at 2:00 PM Level of Harm - Minimal harm or potential for actual harm April 17, 2024, at 6:00 AM April 18, 2024, at 2:00 PM Residents Affected - Some April 19, 2024, at 2:00 PM April 23, 2024, at 2:00 PM April 25, 2024, at 6:00 AM April 29, 2024, at 6:00 Am and 2:00 PM April 30, 2024, at 6:00 AM In an observation and interview on 04/28/2024 at 10:51 AM, Resident #16 was sitting in his chair watching TV. He stated that his catheter had been bugging him at times. He stated that he felt pressure and uncomfortable at times. He stated it had been like this since it was changed, but he was unsure of the exact date. He stated there were times they did not flush it or clean it; he was unsure how often. He stated that he calls his family member often. The catheter was secured to his leg. On the urine drainage port, it reflects an 18 French. He had clear yellow urine in the drainage bag. In a telephone interview on 04/30/2024 at 2:33 PM, Family Member-A revealed that PA-A and MD-A were his attending physicians that seen him regularly. She stated that, Resident #16 called her every night to tell her what all was going on and that he complained periodically about his catheter care not being performed. She stated that she came up to the facility last week to talk to the Administrator, but he was not there. She was wanting to discuss how Resident #16's catheter was irritating him and that she wanted it looked at. She stated that she did not feel like it was checked daily and that she or a family member came to the facility every day to check on the resident. In a telephone interview on 04/30/2024 at 3:16 PM, PA-A who was the PA for MD-A stated that Resident #16 has a catheter change ordered every 30 days as standard and PRN, as needed. Expectations were to be changed as ordered or for them to be called back and updated if it was not changed. She stated a 16 French was ordered for the resident, he should not have an 18 French. She said that he was seeing MD-B before he came into the facility and then the facility took over the catheter care and orders. The MD-A was unavailable for interview and referred the call to the PA-A, who had been treating him under MD-A. In an interview, on 05/01/2024 at 11:00 AM, the DON revealed that the orders were not documented correctly, and she would correct it and that it should have included the size and type on the order. She revealed that the catheter had been changed as ordered. She stated that the catheter instructions for care, irrigation, size, and output should be completed accurately and documented. She revealed this failure could result in the resident getting an infection such as a urinary tract infection. She revealed that she had updated the orders since they failed to enter the catheter size order correctly. A record review of the facility's policy Bowel and Bladder Continence Management dated 05/14. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 7 of 31 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 05/01/2024 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 0690 Indwelling Catheter Evaluation and Management Level of Harm - Minimal harm or potential for actual harm Procedure: Residents Affected - Some 3. Obtain physician order to include: medical diagnosis, justification for use, length of time for use, catheter type and size. 6. Utilize the softest and narrowest catheter to possible to effectively drain the bladder. - Do not treat leakage around the catheter by utilizing a larger catheter, and less medically justified. Address other factors for leakage including, but not limited to- bladder spasm, Constipation, improper catheter positioning. 9. Record any catheter related problems. 11. Monitor for catheter for need for replacement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 8 of 31 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 05/01/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 2 of 2 residents (#5 and #30) reviewed for respiratory care. Residents Affected - Few A. The facility failed to ensure oxygen tubing for Residents #5 were changed weekly. B. The facility failed to ensure Resident #5's nebulizer mask was dated or kept in a bag while not in use. These failures could place residents at risk for infections and transmission of communicable diseases. Findings included: Resident #5 Record review of Resident #5's Face Sheet, dated 04/30/2024, revealed she was a [AGE] year-old female, admitted to the facility on [DATE]. Diagnosis was chronic combined systolic and diastolic heart failure (heart not pumping blood efficiently). Record review of Resident #5's MDS Annual Assessment, dated 09/21/2023 revealed a BIMS score of 09 (moderate cognitive impairment). Section I: Active diagnosis revealed chronic pulmonary disease, or chronic lung disease. Section O: Respiratory Treatments was marked for Oxygen Therapy. Record review of Resident #5's Care plan dated 3/21/2024 revealed in part Focus: oxygen therapy related to end stage congestive heart failure, ineffective gas exchange, terminal prognosis. Intervention/tasks: Weekly tubing and nasal cannula change and check oxygen concentrator. Date and tag tubing, change date. In an observation and interview on 04/28/2024 at 09:40 AM during initial rounds, Resident #5 was lying in her bed receiving humidified oxygen via nasal cannula at 3 liters per minute. Her oxygen tubing was dated 3/18/2024. The humidifier bottle was not dated. The resident stated she did not remember when her oxygen tubing was changed. In an observation on 04/29/2024 at 10:00 AM Resident #5's nasal cannula was dated 3/18/2024. The humidifier bottle was not dated. Resident #30 Record review of Resident #30's Face Sheet dated 04/30/2024 revealed a [AGE] year-old male, who was admitted to the facility on [DATE]. Diagnosis was obstructive pulmonary disease (a lung disease that block airflow and make it difficult to breathe). Record review of Resident #30's MDS admission assessment dated [DATE] revealed a BIMS score of 07 (severe cognitive impairment). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 9 of 31 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 05/01/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #30's Care plan dated 4/22/2024 revealed focus: has altered respiratory status/difficulty breathing. Interventions: administer medication/puffers as ordered. Monitor for effectiveness and side effects. Monitor for signs and symptoms of respiratory distress. Record review of Resident #30's Physician's orders dated 04/2024 revealed Yupelri Inhalation Solution 175mcg/3ml inhale one unit orally in handheld nebulizer one time daily. In an observation and interview on 04/28/2024 at 10:23 AM during initial rounds, Resident #30 was sitting in his bed not using handheld nebulizer. Mask to nebulizer was sitting on nightstand, not in a bag and tubing was not dated. Resident stated that he had a long night and was tired but was unable to answer questions regarding mask. In an Interview on 05/01/2024 at 09:45 AM with the DON, she stated the night shift nurse changes the oxygen tubing weekly based on the resident's orders, or as needed if they become contaminated or occluded. The DON stated oxygen tubing and the humidifier bottle should be changed per doctor's orders. If they were not labeled, she stated she would discard them and replace it with a new nasal cannula. She stated nebulizer masks should be stored in a plastic bag when not in use to prevent cross contamination and infection. Record review of the facility policy Medication Administration, Nebulizer dated 01/2013, revealed the following [in part]: 16. Store the dry nebulizer in a storage bag labeled with resident/patient's name and date. Record review of the facility policy Oxygen Administration, Nasal Cannula, dated as revised on 06/15/2021, revealed the following [in part]: Purpose: To provide the resident/patient with enhanced oxygen concentration of inspired room air. Procedure: 7. Date disposable supplies upon opening. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 10 of 31 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 05/01/2024 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 2 of 3 months (October, November) reviewed for nursing services. The facility failed to provide Registered Nurse (RN) coverage for 8 consecutive hours on 2 days in October 10/1/2023, 10/15/2023, and 1 day in November 11/19/2023. This failure placed could place the residents at risk for altered physical, mental, and psychological well-being due to decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff. Findings included: Record review of the facility's nursing schedule for RN coverage for October, November, and December 2023 revealed, the Director of Nurses worked Monday through Friday upon her start date of November 8, 2023. Review of RN coverage for October and Novemberand November 2023 revealed onrevealed on there was no coverage on the following dates: Sunday 10/1/2023, Sunday 10/15/2023, and Sunday 11/19/2023. In an interview with the Director of Nurses on 05/01/2024 at 10:33 AM, she stated she was not employed by the facility in the month of October 2023; however, her expectation was that the facility had seven day a week RN coverage. The DON further stated, not having RN coverage 7 days a week could put the residents at risk of not having their healthcare needs managed properly. In an interview with the Administrator on 05/01/2024 at 1:32 PM, he stated he was not yet employed by this the facility but it was his expectation that they provided RN coverage seven days a week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 11 of 31 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 05/01/2024 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to post the actual hours worked by the licensed and unlicensed nursing (RN, LVN and CNA) staff directly responsible for resident care per shift daily. Residents Affected - Many The daily nursing staffing information was posted but did not include the total numbers of actual hours worked for RNs, LVNs, and CNAs. The facility's failure could affect the residents and/or visitors to the facility who may desire to know how many nursing staff were present and on duty and the actual hours worked per each shift daily. The findings included: In an observation on 04/28/2024 at 9:45 a.m. the facility's daily nursing posting failed to indicate the actual hours worked for each direct care staffing type. In an observation on 04/29/2024 at 9:00 a.m. the facility's daily nursing posting failed to indicate the actual hours worked for each direct care staffing type. In an observation on 04/30/2024 at 10:00 a.m. the facility's daily nursing posting failed to indicate the actual hours worked for each direct care staffing type. In an observation on 05/01/2024 at 11:00 a.m. the facility's daily nursing posting failed to indicate the actual hours worked for each direct care staffing type. In an interview on 05/01/2024, the DON said the daily nursing posting was not correct. She further stated the form should have been filled out completely and noted it had several blanks and it did not have the total number and actual hours worked. She stated that it should be posted per policy. She said failure to post the actual hours worked had the potential to prevent residents and/or visitors to the facility who may desire to know how many nursing staff were present and on duty and the actual hours worked per each shift daily. In an interview on 05/01/2024 at 1:32 PM, the Administrator stated his expectation was to follow policy and that the policy was not followed due to the total numbers of actual hours worked for RN's, LVN's and CNA's, and the census at beginning of each shift were not on the posting. He further stated that they would modify the form to include the required posting information. Record review of the facility's policy Staffing Information Posting, dated as revised September 2014, reviewed November 2019 revealed the following [in part]: Overview: In accordance with federal regulation, facility census and nursing staff information is posted on each shift. Information required to be posted includes: facility name and date, facility census at the start of each shift, number of RN's, LVN and CNA's providing direct care, actual number of hours of direct care provided, total number of staff and total actual hours of direct care provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 12 of 31 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 05/01/2024 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 - 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 residents were free of significant medication errors in accordance to accepted professional standards and principles for 1 of 6 residents (Resident #14) reviewed for medication administration accuracy. Residents Affected - Few The facility failed to administer Resident #14's insulin as ordered by their physician. This failure could place residents receiving insulin at risk for adverse consequences by not receiving therapeutic dosages of their medications as ordered by the physician. Findings included: Record review of Resident #14's face sheet dated 05/01/2024 revealed the resident was a 76 -year-old female readmitted to the facility on [DATE] with a diagnosis which included Type 2 Diabetes with Diabetic Chronic Kidney Disease (uncontrolled blood sugar caused kidney damage), Diabetes Mellitus with underlying condition with polyneuropathy (uncontrolled blood sugar that causes nerve damage throughout the body). Record review of Resident #14's Physician orders, dated April 2024, revealed the following insulin order: -Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML. Inject 45 unit subcutaneously one time a day at 7:00 AM related to Type 2 Diabetes with Diabetic Chronic Kidney Disease -Order Date- 04/15/2024 - Freestyle Libre Reader Device (Continuous Blood Glucose System Receiver) before meals and at bedtime- ordered times: 6:30 AM, 11:30 AM, 4:30 PM and 8:00 PM, related to Type 2 Diabetes with Diabetic Chronic Kidney Disease -Order Date- 04/15/2024 Record review of Resident #14's Administration record for April 2014, revealed the following late administration times for Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML. Inject 45 unit subcutaneously one time a day at 7:00 AM: - April 16, 2024, administered at 8:24 AM - April 18, 2024, administered at 8:04 AM - April 19, 2024, administered at 10:09 AM - April 28, 2024, administered at 9:36 AM - April 29, 2024, administered at 8:44 AM Interview on 04/29/2024 at 7:54 AM, LVN A stated nurses often get behind on medication pass including insulin, because they are helping other staff members. She did not remember any previous instances where she was behind, but if she was it was for the same reasons. She said this failure could cause the residents to not receive their medications as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 13 of 31 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 05/01/2024 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 - Minimal harm or potential for actual harm Residents Affected - Few In an observation and interview on 04/29/2024 at 8:21 AM, revealed LVN B was starting a medication pass on Resident #14. The resident had finished her breakfast and was sitting in the dining room waiting for her medication. The computer showed the insulin order in red and was marked as late. LVN B stated that she was running behind on the medication pass and had not had a chance to administer her inulin that was ordered at 7:00 AM. She stated that her blood sugar was taken an hour earlier, but she did not administer the medication then. In an observation on 04/29/2024 at 8:44 AM, revealed LVN B administering the Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML. Inject 45 unit subcutaneously, on her abdomen for Resident #14 in the dining room. In an interview with the DON, on 04/29/2024 at 9:04 AM, revealed she expected the nurses to administer medications per physician orders. She stated that they were regularly late in the morning because they got sidetracked helping other staff members, but the insulin should be given as ordered and a priority. She revealed that Resident #14 was ordered at 7:00 AM, and it should have already been administered. She revealed that she has trained her staff on administration times of medications, which included insulin. She said that this failure could place residents at risk of not having the blood sugar and diabetes managed properly. A record review of the facility's policy titled; Medication Administration dated 01/2013 revealed the following: Purpose: To administer the following according to the principles of medication administration, including the right medication, to the right resident/patient at the right time, and the right dose and route. Procedure: -Review physicians' orders for medications to be administered. -Review any special precautions and perform needed evaluations prior to administering medication to the resident/patient. -Perform needed evaluations prior to administering specific medications (example: blood glucose) -Read the medication administration record (MAR) for the ordered medication, dose, route, and time. -Verify the following, again, by comparing medication to MAR prior to administering. -Time Insulin Injection: Purpose: To safely administer an insulin injection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 14 of 31 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 05/01/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 medications were secured on 1 of 2 (Medication Cart A) medication carts and 1 of 1 medication rooms reviewed for pharmacy services. The facility did not ensure medications carts and mediation storage room were secured and locked. This failure could place the residents at risk of a drug diversion. Findings included: During an observation and interview on 04/29/2024 at 3:24 PM, LVN A left the Medication Cart A she was assigned to unlocked inside the unlocked medication room with the door propped open. She revealed that she left the medication cart unlocked accidentally and that the medication room door was closed when she left her cart. She revealed that this failure could cause a resident to gain access to her meds in the unlocked cart or the unlocked opened medication room. During an observation and interview on 05/01/2024 11:15 AM, LVN A left the Medication Cart A she was assigned to unlocked inside the unlocked medication room with the door open. She revealed that she left the medication cart unlocked inside of the medication room that was unlocked, but she thought the door was closed. She stated that she went down to help another nurse with a resident's wound care. She stated that the cart was assigned to her and that she was the one responsible for the medications in the med cart. She revaled this failure could cause residents to gain assess to her meds. During an interview on 05/01/2024 at 11:25 AM, the DON said that her expectations were for medications to be locked up anytime a nurse walks away from it. She stated that the nurse that is assigned to that cart is the nurse that is responsible for it. She said that staff are all trained on medication expectations and know not to leave med carts unlocked or the medication room unlocked. During an interview and observation on 05/01/2024 at 11:30 AM, the Administrator stated he was putting up a new sign on the medication room door that stated the medication room door is to be closed and locked at all times when they walk away. He stated that is expectation are for nurses to follow their policies and procedures and that he would be following through with enforcing these policies. A policy and procedure titled; Medication Administration dated 01/2013 revealed the following: Overview: 14) Lock mediation care. Never leave the medication cart open or unattended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 15 of 31 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 05/01/2024 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all residents were provided a nourishing, palatable well-balanced diet that meets daily nutritional and special dietary needs for 1 of 36 (Resident #6) resident reviewed for needs and preferences. The facility failed to ensure Resident #6 received a Carbohydrate controlled diet with added protein powder to his food three times a day as ordered. This failure placed residents at risk of not having their needs met resulting in delayed healing of pressure ulcer. Findings included: A record review of Resident #6's face sheet dated 4/30/2024 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of type 2 diabetes mellitus with diabetic chronic kidney disease (body doesn't produce enough insulin causing high blood sugar level negatively effecting the kidneys), pressure ulcer to right ankle unstageable (wound to right ankle), essential hypertension (high blood pressure), and muscle weakness. A record review of Resident #6's quarterly MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated no cognitive impairment. A record review of Resident #6's care plan last revised on 3/18/2024 revealed he had a potential nutritional problem related to diabetes, prior CVA , obesity. 3/14/2024 new diet orders from Dr per dietician recommendation carbohydrate controlled, low potassium foods, no added salt and continue protein powder three times a day with meals. A record review of Resident #6's physician orders reflected an order dated 3/15/2024 to continue protein powder three times a day in foods. A record review of Diet Type Report dated 4/30/2024 revealed Resident #6's diet to be carbohydrate controlled and continue with protein powder three times a day in foods. During an observation and interview on 4/29/2024 at 12:18 PM, Resident #6 was observed sitting in his chair eating lunch on bedside table. No carbohydrate-controlled diet noted per doctor order. Resident had full size dessert on tray. Resident #6 stated that he watched his sugar and did not eat lots of his in-room snacks if he ate a full dessert at mealtimes. When asked about protein powder to food at all meals, Resident #6 stated that he was unaware of need for that and to his knowledge had never received any. During an interview on 4/29/2024 at 3:40 PM, the DON stated her expectation was for physician ordered diets to be followed, further stating that if the physician orders were not followed it could result in poor clinical outcomes for residents. During an interview on 4/29/2024 at 5:40 PM, the Administrator stated his expectation was that all diets should be per physician order and should be served according to policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 16 of 31 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 05/01/2024 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 4/30/2024 at 11:46 AM the registered dietician stated that the dietary manager should follow diet order. She further stated that failure to follow dietary physician orders would be a liability and needs to be documented and corrected. During an observation and interview on 4/30/2024 at 5:17 p.m., revealed LVN B sent tray back to kitchen for incorrect diet (carbohydrate controlled), Dietary supervisor stated, just take the bread off, its fine. LVN B stated she had checked the trays at mealtimes for diet. She further stated that when a tray was incorrect in comparison to order she sent it back to the kitchen. During an interview on 4/30/20254 at 5:22 PM, with Resident #6 Physician, he stated that her expectation was for diets to be followed as ordered, further stated that failure to follow dietary orders could result in negative effects such as delayed wound healing, increase in wound occurrence and increase in blood sugar. During an interview on 4/30/2024 at 5:27 PM, the Dietary Supervisor stated that she had not been using protein powder in Resident #6's food as ordered, but that she would order some. She further stated that for carbohydrate-controlled diet its discretionary, I just remove the bread. A record review of the facility's policy titled Therapeutic Diets dated 5/2014, revised 9/2017 reflected the following: Policy Statement All residents have a diet order, including, regular, therapeutic and texture modification, that is prescribed by the attending physician, physician extender, or credentialed practitioner in accordance with the applicable regulatory guidelines. Procedures: 1. The Licensed Nurse accepts the diet order from the authorized prescriber. 2.The Licensed Nurse completes and signs the diet requisition form including the full diet order, food allergies and specific food preference request. 3. Diets are prepared in accordance with the guidelines in the approved diet manual and the individualized plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 17 of 31 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 05/01/2024 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review the facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses or the facility's resident population in accordance with the facility assessment for 1 of 1 (the Dietary Supervisor) reviewed for dietary manager The facility failed to ensure the Dietary Supervisor completed an approved dietary manager training course. This failure could place the residents at risk for compromised nutritional status, weight loss, and compromised health conditions and not being accurately assessed for nutritional status, needs, and preferences. The findings include: Record review of the dietary employee safe food handling training certificates revealed the Dietary Supervisor had a food handler's certificate but did not have manager's safe food handling training. There was no documented evidence the Dietary Supervisor had a certificate for completing a certified dietary manager course. In an interview on 04/30/2024 at 11:50 PM with the BOM revealed training and completions for dietary supervisor had not been completed. The BOM revealed that dietary supervisor had a food handler's card on record but not a food safety training program, nor had she completed a certified food manager program. In an interview on 04/30/2024 at 2:00 PM the Dietary Supervisor stated she had not completed the manager food safety training program nor the food service director course with diabetic training. She has been employed in this position since February 2023 and started the dietary manager course in July of 2023. Record review of Dietary Supervisor job description dated 11/2022 was signed by dietary supervisor February 10,2023. Job description for Dietary Supervisor revealed the following (in part): Essential Duties: Ensures food is nutritional, appetizing, prepared as planned and served in a timely and pleasant manner. Education and Experience: Be a graduate of an accredited course in diabetic training approved by the American Diabetic Association. Must be registered as a Food Service Director in the state. Record review of Professional Staffing policy dated 5/2014, revised 9/2017 revealed the following (in part): A qualified director of food and nutrition services is one who: Is a certified dietary manager, or Is a certified food service manager. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 18 of 31 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 05/01/2024 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 0801 The U.S. Food and Drug Administration, 2022 Food Code specified: Level of Harm - Minimal harm or potential for actual harm 2-102.12 Certified Food Protection Manager Residents Affected - Many (A) The PERSON IN CHARGE shall be a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 19 of 31 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 05/01/2024 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 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 one of one kitchen, in that: The facility failed to store foods in the nonperishable food storage room that were sealed and labeled with an opened date. The facility failed to store foods in the refrigerator and freezer that were sealed and labeled with an identifier and/or opened date. These failures could place residents at risk for decline in nutritional health status and foodborne illness. The findings included: In an observation on 4/28/24 at 8:42 AM, during the initial tour of the facility kitchen revealed the following: Refrigerator: *Sweet N Sour sauce-No open date *1-gallon jar-unknown substance, no open date *1 clear plastic zipper sealed bag with 1 sliced lemon-No label with an identifier to indicate the food item, or when it was placed in the bag. *1 bottle of ketchup-No open date *1 large clear plastic zipper sealed bag with a round white meat-Dietary aide stated it was sliced sandwich turkey- that had no label to identify the food item or when it was placed in the bag. *Bottom shelf-had a shallow lipped lip that had a long round log wrapped in foil on top of lid- [NAME] A said it was ground hamburger meat that was pulled from freezer yesterday (4/27/24)- had no label to identify what the food item was. *3 large containers that had no label to identify the food item-Cook A stated were all donuts that had been donated to the facility the day before. *1 large cookie sheet with foil covering the food item-Cook A stated were apple fritters that a local donut shot donated to the facility the day before.- had no label to identify the food item. Cook A stated that anything that was put in the refrigerator that was opened needed a label to identify what the food item was, and the label needed a date that the food item was opened. Dry storage: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 20 of 31 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 05/01/2024 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 0812 *1 clear plastic zipper sealed bag with opened brown sugar inside- no opened date on the bag. Level of Harm - Minimal harm or potential for actual harm *1 bag of small marshmallows- opened with no open date *1-50# bag of rice- not sealed Residents Affected - Many *1 1/2 loaf of [NAME] bread with no opened date *1 1/2 bag of dinner rolls with no opened date In an interview on 4/28/24 at 9:45AM with Dietary Supervisor revealed that her expectation was for food to be labeled and dated upon opening as well as should be in a sealed container. Review of the facility policy for Food Storage: Dry Goods dated 5/2014 revised 9/2017 revealed (in part): Policy: All dry good will be appropriately stored in accordance with the FDA Food Code. Procedures: 5. All packaged and canned food items will be kept clean, dry and properly sealed. 6. Storage areas will be neat, arranged for easy identification and date marked as appropriate. Review of the facility policy for Food Storage: Cold Foods dated 5/2014 revised 9/2017, 4/2018 revealed (in part): Policy Statement: All time/temperature control for safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. Procedures: 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 21 of 31 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 05/01/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain clinical records that were complete and/or accurate for 1 of 12 (Resident #16) residents reviewed for clinical records in that: The facility did not maintain accurate and current nursing progress notes related to catheter care for Resident #16. The facility did not maintain accurate and current medication records for Resident #16. This failure could place residents at risk for improper documentation. The findings were: Record review of Resident #16's electronic face sheet dated 05/01/2024 revealed he was a [AGE] year old male that was re-admitted to the facility on [DATE] with a diagnosis that included congestive heart failure (heart does not pump blood adequately), neuromuscular dysfunction of the bladder (unable to control bladder due to nerve damage), hypertension (high blood pressure) and prostatic hyperplasia with lower urinary tract symptoms (enlarged prostate, which includes frequent urination, weak urine stream and inability to urinate). Record review of Resident #16's Quarterly MDS dated [DATE] revealed the following: *Section C- Cognitive Patterns revealed a BIMS score of 10 (moderate cognitive impairment). *Section H-Indwelling Catheter revealed that the resident does have an indwelling catheter. Record review of Resident #16's Comprehensive Care plan dated 02/09/2024 revealed the following: Focus: Resident #16 has long term indwelling Foley catheter: neurogenic bladder, history of long-term catheter use, and ongoing follow up by your urologist. Goal: resident #16 will remain free from catheter related trauma through review date. Interventions/Tasks: Resident #16 has a Foley catheter. Position catheter bag and tubing below the level of the bladder and away from the entrance room door. Foley catheter's privacy bag to Foley catheter drainage bag. Record review of Resident #16's April 2024 TAR orders revealed and order to change foley catheter bag and tubing every month on the 10th on the night shift and document in nursing notes. Record review if Resident #16's April 2024 TAR revealed that his catheter was changed on Wednesday, 04/10/2024 during the night shift. Record review of Resident #16's EMR dated 0/10/2024, revealed there was not a nursing note entered as ordered for the catheter change. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 22 of 31 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 05/01/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #16's April 2024 MAR revealed that medications were not documented as given, refused, absent outside of the facility, held or vitals outside of parameters for the following medications, dates, and times: 1) Residents Affected - Few Diltiazem HCl ER Oral Capsule, Extended Release 24 Hour 180 MG (Diltiazem HCl). Give 1 capsule by mouth in the morning related to hypertension (high blood pressure). -Order Date- 04/14/2023. No documentation on the following dates and times: April 19, 2024, and April 20, 2024, at 8:00 AM. 2) Docusate Sodium Capsule 100 MG, give 2 capsules by mouth at bedtime for 2 capsules at bedtime related to constipation (difficulty having a bowel movement). -Order Date- 06/14/2023. No documentation on the following date and time: April 19, 2024, at 6:00 PM. 3) Finasteride Tablet 5 MG Give 1 tablet by mouth in the morning for 5MG daily in the AM related to neuromuscular dysfunction of the bladder (difficulty urinating due to nerve damage or injury). -Order Date07/04/2022. No documentation on the following dates and times: April 19, 2024, and April 20, 2024, at 8:00 AM. 4) Linzess Oral Capsule 72 MCG (Linaclotide) Give 1 capsule by mouth in the morning for chronic idiopathic constipation relate to constipation. Assess for signs and symptoms of adverse effects: Assess bowel function. Order Date- 04/12/2024. No documentation on the following dates and times: April 19, 2024, and April 20th at 7:00 AM. 5) Metamucil Oral Powder 28.3 % (Psyllium). Give 1 Tbsp by mouth in the morning for Constipation (difficulty having a bowel movement). Add to 8 oz PRUNE JUICE -Order Date- 08/28/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 23 of 31 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 05/01/2024 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 0842 No documentation on the following dates and times: Level of Harm - Minimal harm or potential for actual harm April 19, 2024, and April 20th at 7:00 AM. 6) Residents Affected - Few Omeprazole 20 MG Capsule delayed release. Give 1 capsule by mouth in the morning related to reflux (acid from the stomach moves up into the esophagus). -Order Date- 04/27/2023. No documentation on the following dates and times: April 19, 2024, and April 20th at 7:00 AM. 7) Refresh Tears Ophthalmic Solution 0.5 % Carboxymethylcellulose Sodium. Instill 2 drops in both eyes at bedtime for dry eyes -Order Date- 06/29/2023. No documentation on the following date and time: April 19, 2024, at 6:00 PM. 8) Remeron Tablet 15 MG (Mirtazapine). Give 1 tablet orally at bedtime for Major depressive disorder (persistent disorder characterized by mood or loss of interest in activities). -Order Date- 06/14/2023. No documentation on the following date and time: April 19, 2024, at 6:00 PM. 9) Senna-Docusate Sodium Tablet 8.6-50 MG (Sennosides-Docusate Sodium). Give 1 tablet by mouth at bedtime for intestinal obstruction (blockage in the intestines). -Order date- 06/14/2023. No documentation on the following date and time: April 19, 2024, at 6:00 PM. 10) Synthroid Oral Tablet 100 MCG (Levothyroxine Sodium). Give 100 mcg orally in the morning related to Hypothyroidism (thyroid gland does not produce enough thyroid hormones). -Order Date- 09/29/2023. No documentation on the following dates and times: April 12, 2024, and April 18, 2024, at 6:00 AM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 24 of 31 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 05/01/2024 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 0842 11) Level of Harm - Minimal harm or potential for actual harm Tylenol Oral Tablet 325 MG (Acetaminophen) Give 650 mg orally at bedtime for Moderate Pain Give (2) MG -Order Date- 09/29/2023. Residents Affected - Few No documentation on the following date and time: April 19, 2024, at 8:00 PM. 12) Apixaban Tablet 2.5 MG Give 1 tablet by mouth two times a day for ONE 2.5MG tab two times per day. Assess for signs and symptoms of hemorrhage (uncontrolled bleeding) and document. Notify MD PRN. -Order Date- 06/06/2023. No documentation on the following dates and times: April 19, 2024, at 8:00 AM and 6:00PM. April 20, 2024, at 8:00 AM. 13) Ferrous Sulfate Tablet 325 (65 Fe) MG. Give 1 tablet by mouth with meals for ONE TAB by mouth 3X per day **with meals** No crush/chew, related to anemia (blood doesn't have enough healthy red blood cells and hemoglobin). -Order Date- 06/10/2022. No documentation on the following dates and times: April 19, 2024, at 8:00 AM and 5:00 PM. April 20, 2024, at 8:00 AM and 12:00 PM. 14) Carafate Oral Tablet 1 GM (Sucralfate) Give 1 tablet by mouth four times a day related to intestinal obstruction (blockage in intestines) before meals -Order Date- 06/15/2023. No documentation on the following dates and times: April 19, 2024, at 7:00 AM, 4:00 pm and 8:00 PM. April 20, 2024, at 7:00 AM and 11:00 AM. Record review of Resident #16's April 2024 Nursing notes did not reflect or note any medications that were refused, held or vitals outside of parameters and that the resident was absent or outside of the facility during medication pass. In an interview on 04/30/2024 at 4:19 PM, the DON stated that upon her review there was no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 25 of 31 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 05/01/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documentation reflecting the resident's catheter change on April 10, 2024, under nursing notes as ordered. She stated that the documentation of the medication pass times that were refused or missed for any not administered for any reason should show that on EMAR. She stated that the nursing notes reflect that the resident had not left the facility since March 2024 and that all the medications were given, just not documented. She was unsure why it was not documented, and which nurses missed the documentation, but that all nursing staff had been trained on documentation and following orders. She revealed that she was responsible for ensuring that documentation was entered. She revealed this failure could result inaccurate documentation. A record review of the facility's policy titled; Clinical Programs Manual dated 06/2015 revealed the following: Documentation: Form Completion Directions: Progress Notes Purpose: To document narrative account of resident patient care period documentation may be completed electronically using facility approved E. H. R. Software. Responsible Person: All staff documenting in the medical record. When: Upon admission. As needed to record resident/patient care. Instructions: 2) Enter date and time of the entry. 3) Record entry. Document legibly. 4) Refer to guidelines on documentation for further information. Interview with the DON on 05/01/2024 at 11AM, A copy of the facility's policy covering documentation and medication administration documentation was requested and was not provided at the time of exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 26 of 31 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 05/01/2024 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 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. Level of Harm - Minimal harm or potential for actual harm Based on record reviews and interviews, the facility failed to maintain a general training program to ensure staff were trained for 4 of 10 (RN B, LVN C, CNA D, CNA E) reviewed for general training. Residents Affected - Few The facility failed to ensure all staff were trained for communication. The facility failed to ensure all staff were trained for QAPI. The facility failed to ensure all staff were trained for Behavioral Health. The facility failed to ensure all staff were trained for HIV. The facility failed to ensure all staff were trained for Restraint Reduction. The facility failed to ensure all staff were trained for Falls. These failures could place residents at risk of at receiving care from incompetent/untrained staff. Findings included: Record Review of Personnel Files revealed the following staff did not receive the following training: *RN B hired 08/22/2022Communication QAPI Behavioral Health HIV Restraint Reduction Falls *LVN C hired on 06/11/2022HIV. *CNA D hired 03/15/2024 QAPI Behavioral Health (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 27 of 31 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 05/01/2024 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 0940 Restraint Reduction Level of Harm - Minimal harm or potential for actual harm *CNA E rehired on 12/15/2023 Communication Residents Affected - Few Behavioral Health Restraint Reduction In an interview with the HR on 04/30/2024 at 10:00AM revealed that she was responsible for orientation training and each department head was responsible for all other trainings. She said she had specific trainings that the facility did each month throughout the year, and she would ensure those in attendance signed the in-service training sheets; however, after the meetings those in-service trainings were the responsibility of each department head to ensure their staff received the trainings. In an interview with the DON on 05/01/2024 at 10:30AM, she said she was responsible for ensuring her staff received all the required training. She said there were staff that did not attend the meetings to get the in-service trainings, so she would take the book with her and tell the staff that they had in-service training and the staff needed to read over the material and sign the sheets that they received the information. The DON said staff would say they would get to it later, they needed to go answer call lights or were too busy at that time. Record review of facility policy labeled Training Compliance undated revealed: Orientation All newly hired employees will attend new employee orientation within the first 5 days of employment. The department head or designated department representative will conduct specific department and job orientation. Compliance Training The Corporate Compliance Program is legally required under federal law and is aimed at educating employees on appropriate policies, practices and procedures that comply with all applicable laws. All employees must read and acknowledge receipt of the Corporate Compliance Guidelines within the first week of employment and annually thereafter. All employees are also required to participate in the general compliance training and depending upon their position, HIPPA, and other job-specific trainings. Initial compliance training must take place within 30 days of your employment, and as necessary thereafter. Record review of facility Handbook dated 8/18/2022 revealed: Meetings: You are expected to attend designated meetings to foster communications about issues. Some in-services are mandatory, and employees must attend. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 28 of 31 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 05/01/2024 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 0941 Level of Harm - Potential for minimal harm Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Based on record reviews and interviews, the facility failed to maintain a training program to ensure staff were trained for 2 of 10 (RN B, CNA E) reviewed for communication training. Residents Affected - Some The facility failed to ensure all direct care staff were trained on communication. This failure could place residents at risk at receiving care from incompetent/untrained staff. Findings included: Record Review of Personnel Files revealed the following staff did not receive training for communication: *RN B hired 08/22/2022 *CNA E rehired on 12/15/2023 In an interview with HR on 04/30/2024 at 10:00AM revealed that she was responsible for orientation training and each department head was responsible for all other trainings. She said she had specific trainings that the facility did each month throughout the year, and she would ensure those in attendance signed the in-service training sheets; however, after the meetings those in-service trainings were the responsibility of each department head to ensure their staff received the trainings. In an interview with DON on 05/01/2024 at 10:30AM, she said she was responsible for ensuring her staff received all the required training. She said there were staff that did not attend the meetings to get the in-service trainings, so she would take the book with her and tell the staff that they had in-service training and the staff needed to read over the material and sign the sheets that they received the information. DON said staff would say they would get to it later, they needed to go answer call lights or were too busy at that time. Record review of facility policy labeled Training Compliance undated revealed: Orientation All newly hired employees will attend new employee orientation within the first 5 days of employment. The department head or designated department representative will conduct specific department and job orientation. Compliance Training The Corporate Compliance Program is legally required under federal law and is aimed at educating employees on appropriate policies, practices and procedures that comply with all applicable laws. All employees must read and acknowledge receipt of the Corporate Compliance Guidelines within the first week of employment and annually thereafter. All employees are also required to participate in the general compliance training and depending upon their position, HIPPA, and other job-specific trainings. Initial compliance training must take place within 30 days of your employment, and as necessary thereafter. Record review of facility Handbook dated 8/18/2022 revealed: Meetings: You are expected to attend designated meetings to foster communications about issues. Some in-services are mandatory, and employees must attend. ? FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 29 of 31 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 05/01/2024 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 0944 Level of Harm - Potential for minimal harm Residents Affected - Some Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on record reviews and interviews, the facility failed to maintain a training program to ensure staff were trained for 2 of 10 (RN B, CNA D) reviewed for Quality Assurance and Performance Improvement(QAPI) training. The facility failed to ensure all staff were trained for QAPI. This failure placed residents at risk of at receiving care from incompetent/untrained staff. Findings included: Record Review of Personnel Files revealed the following staff did not receive training for Quality assurance and performance improvement: *RN B hired 08/22/2022 *CNA D hired 03/15/2024 In an interview with HR on 04/30/2024 at 10:00AM revealed that she was responsible for orientation training and each department head was responsible for all other trainings. She said she had specific trainings that the facility did each month throughout the year, and she would ensure those in attendance signed the in-service training sheets; however, after the meetings those in-service trainings were the responsibility of each department head to ensure their staff received the trainings. In an interview with DON on 05/01/2024 at 10:30AM, she said she was responsible for ensuring her staff received all the required training. She said there were staff that did not attend the meetings to get the in-service trainings, so she would take the book with her and tell the staff that they had in-service training and the staff needed to read over the material and sign the sheets that they received the information. DON said staff would say they would get to it later, they needed to go answer call lights or were too busy at that time. Record review of facility policy labeled Training Compliance undated revealed: Orientation All newly hired employees will attend new employee orientation within the first 5 days of employment. The department head or designated department representative will conduct specific department and job orientation. Compliance Training The Corporate Compliance Program is legally required under federal law and is aimed at educating employees on appropriate policies, practices and procedures that comply with all applicable laws. All employees must read and acknowledge receipt of the Corporate Compliance Guidelines within the first week of employment and annually thereafter. All employees are also required to participate in the general compliance training and depending upon their position, HIPPA, and other job-specific trainings. Initial compliance training must take place within 30 days of your employment, and as necessary thereafter. Record review of facility Handbook dated 8/18/2022 revealed: Meetings: You are expected to attend designated meetings to foster communications about issues. Some in-services are mandatory, and employees must attend. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 30 of 31 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 05/01/2024 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 0949 Level of Harm - Potential for minimal harm Provide behavior health training consistent with the requirements and as determined by a facility assessment. Based on record reviews and interviews, the facility failed to maintain a training program to ensure staff were trained for 3 of 10 (RN B, CNA D, CNA E) reviewed for behavioral health training. Residents Affected - Some The facility failed to ensure all staff were trained for Behavioral Health. This failure could place residents at risk at receiving care from of incompetent/untrained staff. Findings included: Record Review of Personnel Files revealed the following staff did not receive training for Behavioral health: *RN B hired 08/22/2022 *CNA D hired 03/15/2024 *CNA E rehired on 12/15/2023 In an interview with HR on 04/30/2024 at 10:00AM revealed that she was responsible for orientation training and each department head was responsible for all other trainings. She said she had specific trainings that the facility did each month throughout the year, and she would ensure those in attendance signed the in-service training sheets; however, after the meetings those in-service trainings were the responsibility of each department head to ensure their staff received the trainings. In an interview with DON on 05/01/2024 at 10:30AM, she said she was responsible for ensuring her staff received all the required training. She said there were staff that did not attend the meetings to get the in-service trainings, so she would take the book with her and tell the staff that they had in-service training and the staff needed to read over the material and sign the sheets that they received the information. DON said staff would say they would get to it later, they needed to go answer call lights or were too busy at that time. Record review of facility policy labeled Training Compliance undated revealed: Orientation All newly hired employees will attend new employee orientation within the first 5 days of employment. The department head or designated department representative will conduct specific department and job orientation. Compliance Training The Corporate Compliance Program is legally required under federal law and is aimed at educating employees on appropriate policies, practices and procedures that comply with all applicable laws. All employees must read and acknowledge receipt of the Corporate Compliance Guidelines within the first week of employment and annually thereafter. All employees are also required to participate in the general compliance training and depending upon their position, HIPPA, and other job-specific trainings. Initial compliance training must take place within 30 days of your employment, and as necessary thereafter. Record review of facility Handbook dated 8/18/2022 revealed: Meetings: You are expected to attend designated meetings to foster communications about issues. Some in-services are mandatory, and employees must attend. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 31 of 31