Inspection·November 18, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the morning every Friday related to type 2 diabetes mellitus with hyperglycemia until 10/02/2025 weekly for 4 weeks, scheduled for 0700 (7:00 AM) was not initialed by the nurse on 9/12/2025.- Order dated 7/19/2025 for Ozempic (0.25 or 0.5 mg/dose) subcutaneous solution pen-injector 2 mg/3 ml (Semaglutide). Inject 0.5 mg subcutaneously in the morning every Friday related to type 2 diabetes mellitus with hyperglycemia until 9/11/2025 weekly for 4 weeks, scheduled for 0800 (8:00 AM) was not initialed by the nurse on 9/04/2025.- Order dated 8/21/2025 to announce meal intake into the Insulin Pump 10 minutes prior to eating meal and no later than 10 minutes after starting to eat, with meals related to type 2 diabetes mellitus with hyperglycemia was not initialed by the nurse for 0800 (8:00 AM) on 9/04/25, 9/06/25, 9/12/25; for 1200 (12:00 PM) on 9/06/25 and 9/12/25; and for 1700 (5:00 PM) on 9/06/25 and 9/09/25.- Order dated 8/27/2025 for blood sugars tid before meals and record before meals for hypoglycemia was not initialed by the nurse for 0700 (7:00 AM) on 9/04/25, 9/06/25, and 9/12/25; for 1130 (11:30 AM) on 9/06/25 and 9/12/25; and for 1630 (4:30 PM) on 9/06/25 and 9/09/25. Record review of Resident #4's admission Record, dated 10/02/2025, revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included type 2 diabetes mellitus (the body does not use insulin effectively). Record review of Resident #4's Medication Administration Records, dated 9/01/2025-9/30/2025, revealed the following:Order dated 4/16/2025 for Lantus SoloStar Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) - Inject 30 unit subcutaneously in the morning related to type 2 diabetes mellitus with chronic kidney disease, scheduled for 0700 (7:00 AM) was not initialed by the nurse on 9/06/25, 9/09/25, and 9/12/25.- Order dated 2/03/2023 for fsbs check with sliding scale coverage before meals for fsbs related to Type 2 diabetes mellitus with diabetic chronic kidney disease with sliding scale was not initialed by the nurse and did not have blood sugar levels documented for 1130 (11:30 AM) on 9/06/25, 9/09/25, 9/12/25, and 9/15/25; and for 1630 (4:30 PM) on 9/09/25 and 9/12/25.- Order dated 4/03/25 for Novolog FlexPen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Aspart) - Inject as per sliding scale if:150 - 209 = 1 unit;210 - 269 = 2 unit;270 - 329 = 3 unit;330 - 389 = 4 unit;390 - 449 = 5 unit;Notify Dr. [name] of greater than 375, Subcutaneously before meals and at bedtime for diabetes.The nurse did not document the blood sugar levels, the amount of insulin units if administered, and initial for 0700 (7:00 AM) on 9/06/25, 9/09/25, 9/12/25; for 1130 (11:30 AM) on 9/06/25, 9/099/25, 9/12/25, 9/15/25; for 1630 (4:30 PM) on 9/06/25, 9/09/25, 9/12/25, 9/17/25; and for 2000 (8:00 PM) on 9/05/25, 9/12/25, and 9/23/25. Record review of Resident #7's admission Record, dated 10/02/2025, revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included type 2 diabetes mellitus (the body does not use insulin effectively). Record review of Resident #7's Medication Administration Records, dated 9/01/2025-9/30/2025, revealed the following:- Order dated 10/04/2024 for fasting bbg every morning, scheduled for 0600 (6:00 AM) related to type 2 diabetes mellitus, did not have a documented blood sugar level and was not initialed by the nurse on 9/06/25 and 9/09/25.- Order dated 10/28/2024 for Toujeo SoloStar Subcutaneous Solution Pen-injector 300 unit/ml (Insulin Gargline) - Inject 60 unit subcutaneously in the morning related to Type 2 diabetes mellitus with diabetic neuropathy, scheduled for 0800 (8:00 AM), did not have a documented blood sugar level and was not initialed by the nurse as administered on 9/06/25, 9/09/25, 9/12/25. In an interview on 9/30/25 at 4:48 PM, C.N.A. A stated she was also a medication aide. She stated she worked the day shift (6 AM - 6 PM) on 9/12/25 and the nurse scheduled to work that day called in. She stated RN D came to the facility the morning of 9/12/25. C.N.A. A stated she had given the residents their medications and RN D would have given the insulin injections to two residents - Resident #4 and Resident #7. During an interview and record review on 9/30/25 at 5:10 PM, the DON reviewed the eMARs for Resident #4 and Resident #7 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 2 of 4 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 11/18/2025 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 stated the nurse had not signed off that she had administered the insulin injections for Resident #4 or Resident #7 on 9/12/25. The DON stated both residents had scheduled insulin orders for the morning. She stated there was no way of knowing whether or not the nurse administered the insulin injections. The DON stated the nurse may have done it and just not signed off on the eMAR. The DON stated she had started employment in the facility on 9/23/2025 and did not know who had been scheduled to work prior to that date, as a working nursing schedule had not been kept with documented staff changes. In an interview on 10/01/25 at 1:41 PM, Resident #7 stated she was a diabetic and received an insulin shot in the morning and pills at bedtime. Resident #7 stated she had not missed any insulin injections in the morning. She stated, They know I need it. Resident #7 remembered RN D and stated she had given her insulin shots in the morning and thought she had given the shots twice (on 2 occasions). In an interview on 10/01/25 at 2:47 PM, LVN B stated she was employed in the facility on and off for 2 years and usually worked on the day shift 6 AM - 6 PM. LVN B stated the night shift nurse did the fsbs for the residents with injectable insulin - Resident #4 and Resident #7. She stated the morning of 9/12/2025 the night shift nurse should have done the fsbs for the 2 residents by 6 AM and documented the results on the eMAR. LVN B stated the 2 residents with the insulin pumps (Residents #1 and #2) had their blood sugar checked by a continuous glucose monitor later when served breakfast. She stated the nurse pressed the button for the meal and slid the administer insulin option by touch screen. In an interview on 10/02/25 at 11:53 AM, RN C stated she was employed with the facility since the end of July 2025. RN C stated the nurses checked the diabetic residents' blood sugars before administering insulin injections. She stated sometimes the night nurse did it and sometimes the day shift nurse did it. RN C stated Residents #1 and #2 had insulin pumps and the continuous glucose monitor was tied into their insulin pumps and would read their blood sugars. RN C stated the nurse took the meal trays to Residents #1 and #2. She stated the two residents received insulin before each meal and at bedtime. RN C stated sometimes she checked Resident #7's sugar in the morning, but other times went by the night shift nurse's reading of the resident's blood sugar. She stated Resident #7 received insulin only in the morning and her insulin was long acting. RN C stated she took Resident #4's blood sugar before giving her insulin as she received sliding scale insulin at breakfast and dinner. In an interview on 10/02/25 at 4:48 PM, the DON stated the expectation for the nurses was that they prepared insulin and documented on the eMAR when insulin was administered just like any other medication. She stated the fsbs results were documented on either the eTAR or eMAR. She stated a possible outcome from not doing so could be elevated blood sugars. The DON stated the insulin pumps would release insulin without the meal being selected but it would be released at a later time. Record review of the facility's Policy and Procedure: Administration of Insulin Therapy, dated 7/01/2025, revealed the following specifications [in part]: I. Policy StatementIt is the policy of (facility name) to administer insulin only upon a licensed practitioner's order to maintain therapeutic blood glucose control. Due to the high-risk nature of insulin, administration requires mandatory safety checks, adherence to proper technique, and compliance with State regulations.II. PurposeTo ensure the safe, accurate, and timely administration of insulin, including basal, prandial, and correctional (sliding scale) doses, to standardize protocols for glucose monitoring and management of acute complications (hypoglycemia/hyperglycemia).III. ScopeThis policy applies to all licensed nursing staff (RNs and LVNs), and to unlicensed personnel (CNAs/Medication Aides) only when administration is specifically delegated by a Registered Nurse and is compliant with (state name) Board of Nursing rules.1. Restriction: In a Skilled Nursing Facility, the administration of injectable medications (including insulin) is typically performed by a licensed nurse.D. Monitoring, Storage, and Documentation.4. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 3 of 4 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 11/18/2025 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 Documentation: The administering nurse will document on the MAR:- Insulin Type, Dose, Injection Site, Date, and Time.- BGM result and time immediately prior to insulin administration Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455893 If continuation sheet Page 4 of 4