Inspection·June 7, 2024

F 0580 05/10/24. Level of Harm - Minimal harm or potential for actual harm Interventions: Resident #1 will have no complications resulting from the burns through the review date. Follow treatments as ordered. Residents Affected - Some Record review of Resident #1's EMR Incident Audit report dated 06/04/2024, revealed that on 05/14/2024 the following documentation was charted: On 05/14/2024 at 5:36 PM, DON charted, at approximately 10:30 in the morning, LVN #1 came to see me with Resident #1 and stated that she got a cup of coffee and spilt it on herself. LVN #1 and DON did a skin assessment. Skin was intact and pink, no blisters. Changed clothes. Resident denies pain. On 05/14/2024 at 5:36 PM, the DON charted that on 05/10/2024, changed Resident #1 into dry clothes. ON 05/14/2024 at 5:26 PM, the DON charted the following: per my assessment on the 10th, skin is intact and slightly pink. No blisters noted. On Saturday the 11th, LVN A stated, resident only had a small area of pink skin wasn't hacked and still no blisters. On Sunday the 12th area remains pink on one side intact, no blisters. The opposite side was noted to be of normal color for the resident. On Monday when I arrived it was noted that the resident was rubbing her legs and when the nurse went to check her skin both thighs were noted to be peeling with the pink skin underneath. Record review of Resident #1's EMR dated 06/04/2024, revealed there was a nursing note completed on 05/13/2024 by LVN B, that revealed the following: Notified the Medical Director of Resident #1's burns to upper bilateral thighs from spilling coffee on herself on Friday, May 10, 2024. Ordered to clean burns to bilateral thighs with wound cleanser, pat dry and apply burn cream to wound bed BID for 1 week. 05/14/2024 by LVN B that revealed the following: Called Resident #1's son and notified him of treatment and bilateral burns. There were no nursing notes, incident notes, or progress notes documented on 05/10/2024, 05/11/2024 and 05/12/2024. In an interview on 06/07/2024 at 11:55 AM, the DON stated that she or her nursing staff had not notified the physician after the incident on May 10, 2024, until May 13, 2024. DON stated that she or her nursing staff had not notified the family after the incident on May 10, 2024, until May 14, 2024. She said that with any type of incident or change of condition, the physician and family should be notified immediately. She revealed this failure could result in care issues. Record review of facility policy labeled Change in a Resident's Condition or Status, not dated, revealed the following: Policy Statement: Our facility promptly notifies the resident, his or her attending physician, healthcare provider and the resident's representative of changes in the resident's medical mental condition and or status. Policy interpretation and implementation: 1) The nurse will notify the resident's attending physician, health care provider or physician on call (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 2 of 6 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 06/07/2024 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 0580 when there has been an: Level of Harm - Minimal harm or potential for actual harm d. significant change in the residence physical, emotional, mental condition. e. Need to alter the residence medical treatment significantly. Residents Affected - Some 2) a significant change of condition is a major decline and improvement in the resident status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. b. Impacts more than one area of the resident's health status. c. Requires interdisciplinary review and or revisions to the care plan. 3) The nurse will notify the resident's representative when: b. there is a significant change in the residence physical, mental, or psychosocial status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 3 of 6 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 06/07/2024 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 - Some 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 interview and record review the facility failed to maintain clinical records that were complete and/or accurate for 1 of 3 (Resident #1) residents reviewed for clinical records in that: The facility did not maintain accurate and current nursing progress notes on 5/10/24, 5/11/24, 5/12/24, and 5/13/24 related to an incident that occurred to Resident #1 on 05/10/2024 regarding a coffee burn. This failure could place residents at risk for improper documentation. The findings were: Record review of Resident #1's electronic face sheet dated 06/04/2024 revealed she was a [AGE] year-old female that was admitted to the facility on [DATE] with a diagnosis that included malignant neoplasm of lower lobe (lung cancer), Alzheimer's Disease (disease that destroys memory and other important mental functions) and senile degeneration of brain (cognitive deficits that impair the memory and judgement). Record review of Resident #1's Significant Change MDS dated [DATE] revealed the following: *Section C- Cognitive Patterns revealed a BIMS score of 03 (severe cognitive impairment). *Section M-Revealed that Resident #1 does have burns and is receiving treatment for burns. Record review of Resident #1's Comprehensive Care plan dated 05/30/2024 revealed the following: Focus: Resident #1 has impaired cognitive function/dementia or impaired thought processes related to Alzheimer's. Interventions: Reduce any distractions- turn off TV, radio, close door etc. Resident #1 understands, consistent, simple, directive sentences. Focus: Resident #1 has burns of bilateral lower extremities due to spilling coffee on herself 05/10/24. Interventions: Resident #1 will have no complications resulting from the burns through the review date. Follow treatments as ordered. Record review of Resident #1's EMR Incident Audit report dated 06/04/2024, revealed that there were no nursing notes, incident notes, or progress notes documented on 05/10/2024, 05/11/2024, 05/12/2024 and 05/13/2024. on 05/14/2024 the following documentation was charted: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 4 of 6 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 06/07/2024 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 On 05/14/2024 at 5:36 PM, DON charted, at approximately 10:30 in the morning, LVN #1 came to see me with Resident #1 and stated that she got a cup of coffee and spilt it on herself. LVN A and DON did a skin assessment. Skin was intact and pink, no blisters. Changed clothes. Resident denies pain. On 05/14/2024 at 5:36 PM, the DON charted that on 05/10/2024, changed Resident #1 into dry clothes. Residents Affected - Some On 05/14/2024 at 5:26 PM, the DON charted the following: per my assessment on the 10th, skin is intact and slightly pink. No blisters noted. On Saturday the 11th, LVN A stated, resident only had a small area of pink skin wasn't hacked and still no blisters. On Sunday the 12th area remains pink on one side intact, no blisters. The opposite side was noted to be of normal color for the resident. On Monday when I arrived it was noted that the resident was rubbing her legs and when the nurse went to check her skin both thighs were noted to be peeling with the pink skin underneath. Skin Observation assessments revealed that observations were not documented on 05/10/2024, 05/11/2024, 05/12/2024 and 05/13/2024. In an interview on 06/07/2024 at 11:55 AM, the DON stated that upon her review there was no documentation that was completed on Resident #1's incident from 05/10/2024 when she spilt the coffee, that reflected any assessments, progress notes, incidents, observations, and treatments on the following dates: 05/10/2024, 05/11/2024, 05/12/2024 and 05/13/2024. She said that when the resident spilt coffee on herself, DON and LVN #1 immediately took off Resident #1's clothes and treated her with cool rags. She revealed that she forgot to document the cool rags on any of the days, but that they did apply them immediately to remove the heat. She said that her documentation was wrong and that on May 10th, the area on bilaterally (both thighs) was the size of her hands and was pink. She stated that the documentation was wrong since she entered it 4 days later. She said that she was the person that was responsible for ensuring that documentation was completed when there was a change of condition or an incident. She was unsure why it was not documented by other nurses, but that all nursing staff, including herself, had been trained on documentation. 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. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 5 of 6 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 06/07/2024 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 When: Level of Harm - Minimal harm or potential for actual harm Upon admission. As needed to record resident/patient care. Residents Affected - Some Instructions: 2) Enter date and time of the entry. 3) Record entry. Document legibly. 4) Refer to guidelines on documentation for further information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 6 of 6