Health inspection·January 3, 2025

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 record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days a week for 3 of 12 months (October 2024, November 2024, December 2024) reviewed for RN coverage. The facility failed to ensure that an RN worked 8 consecutive hours a day, seven days a week for 34 days of 92 days in October 2024, November 2024, and December 2024. This failure could place residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff. Findings included: Record review of the PBJ Staffing Data Report, (payroll-based journal nurse staffing and non-nurse staffing datasets provide information submitted by nursing homes including rehabilitation services on a quarterly basis) FY Quarter 1, 2025 (October 1, 2024 - November 30, 2024, December 31, 2024), run date 01/6/25, revealed no evidence of RN coverage for 34 of 92 days: 1. 10/26/2024 with no RN coverage. 2. 10/27/2024 with no RN coverage. 3. 11/3/2024 with no RN coverage. 4. 11/5/2024 with no RN coverage. 5. 11/13/2024 with no RN coverage. 6. 11/16/2024 with no RN coverage. 7. 11/20/2024 with no RN coverage. 8. 11/21/2024 with no RN coverage. 9. 11/22/2024 with no RN coverage. 10. 11/25/2024 with no RN coverage. Page 1 of 4 455893 455893 01/03/2025 Grace Care Center of Henrietta 807 W Bois D Arc Henrietta, TX 76365

F 0727 11. 11/26/2024 with no RN coverage. Level of Harm - Minimal harm or potential for actual harm 12. 11/27/2024 with no RN coverage. 13. 11/28/2024 with no RN coverage. Residents Affected - Some 14. 11/29/2024 with no RN coverage. 15. 12/2/2024 with no RN coverage. 16. 12/3/2024 with no RN coverage. 17. 12/4/2024 with no RN coverage. 18. 12/5/2024 with no RN coverage. 19. 12/6/2024 with no RN coverage. 20. 12/9/2024 with no RN coverage. 21. 12/10/2024 with no RN coverage. 22. 12/11/2024 with no RN coverage. 23. 12/12/2024 with no RN coverage. 24. 12/13/2024 with no RN coverage. 25. 12/16/2024 with no RN coverage. 26. 12/17/2024 with no RN coverage. 27. 12/18/2024 with no RN coverage. 28. 212/19/024 with no RN coverage. 29. 12/20/2024 with no RN coverage. 30. 12/23/2024 with no RN coverage. 31. 12/26/2024 with no RN coverage. 32. 12/27/2024 with no RN coverage. 33.12/30/2024 with no RN coverage. 34. 12/31/2024 with no RN coverage. In an interview and record review on 01/02/2025 at 2:30pm, the Human Resource (HR) provided the 455893 Page 2 of 4 455893 01/03/2025 Grace Care Center of Henrietta 807 W Bois D Arc Henrietta, TX 76365

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some timecard reports for the months of October 2024, November 2024, and December 2024. The HR verbally confirmed there was no RN coverage or a full 8 hours of RN coverage for the dates of : 10/26/2024, 10/27/2024, 11/3/2024, 11/5/2024, 11/13/2024, 11/16/2024, 11/20/2024, 11/21/2024, 11/22/2024, 11/25/2024, 11/27/2024, 11/28/2024, 11/29/2024, 12/2/2024, 12/3/2024, 12/4/2024, 12/5/2024, 12/6/2024, 12/9/2024, 12/10/2024, 12/11/2024, 12/12/2024, 12/13/2024, 12/16/2024, 12/17/2024, 12/18/2024, 12/19/2024, 12/20/2024, 12/23/2024, 12/26/2024, 12/27/2024, 12/30/2024, 12/31/2024. 10/26/2024, 10/27/2024, 11/3/2024, 11/5/2024, 11/13/2024, 11/16/2024, 11/20/2024, 11/21/2024, 11/22/2024, 11/25/2024, 11/27/2024, 11/28/2024, 11/29/2024, 12/2/2024, 12/3/2024, 12/4/2024, 12/5/2024, 12/6/2024, 12/9/2024, 12/10/2024, 12/11/2024, 12/12/2024, 12/13/2024, 12/16/2024, 12/17/2024, 12/18/2024, 12/19/2024, 12/20/2024, 12/23/2024, 12/26/2024, 12/27/2024, 12/30/2024, 12/31/2024. In an interview on 01/02/2025 at 9:35am, the facility's CNO D said her understanding of the facility policy was an RN was to be on staff 8 hours a day. The CNO D stated the facility has weekend coverage for RN hours, and at this point the CNO D stated she can be reached by facility 24/7 by phone if needed. Record review of a policy statement was provided that states A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. 455893 Page 3 of 4 455893 01/03/2025 Grace Care Center of Henrietta 807 W Bois D Arc Henrietta, TX 76365

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to handle, store, process, and transport linens so as to prevent the spread of infection for 1 of 1 laundry carts observed for infection control practices. Residents Affected - Some The facility failed to ensure clean laundry was protected from dust and contamination while being transported to resident's rooms. This failure could place residents at risk for healthcare associated cross-contamination and infections. The findings include: Observation on 01/02/2025 at 11:20 am the HK L was observed delivering clean laundry using a cart that was not covered. The HK L was observed delivering clean laundry to rooms #12 and 14 on the hall labeled Zone 2 on facility map, then moving uncovered cart past lobby and through dining room to Hall labeled Zone 6 to room [ROOM NUMBER]. Interview on 01/02/2025 at 11:30 am the HK L stated she does not have a cover for cart and did not know a cover was required during transport. Interview on 01/02/2025 at 12:10pm the LVN C who was in-charge of facility at time of survey , stated she was unaware that clean laundry was being transported back into the building and deliveries needed to be covered to protect from cross-contamination. Interview on 01/03/25 at 1:00pm LVN C stated the facility did not have a policy for delivery of clean laundry. 455893 Page 4 of 4