Inspection·August 9, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few concerns moments after incident. Resident #3 has no history of aggressive behaviors towards others. LVN A notified the DON, physician, Hospice, and family of both residents. Interview on 8/8/23 at 10:30 am, the DON stated she reported the incident to HHSC on 7/22/23. The DON stated her investigation did not establish what caused the behavior of Resident #3 to try and remove Resident #2 from the table. Neither resident was interview-able and both residents had no concerns or any mental stress. The DON stated she provided in-service training to staff on 7/23/23, topics include Prevention of Physical abuse, Preventing and Recognizing Triggers of Behaviors and Dementia. The DON stated Resident #3 does not have any history of aggression and has not done anything like this before. The DON stated she performed an investigation on incident, but she must have forgotten to submit the PIR findings for incident on 7/22/23, on form (3613-A) to HHSC. Resident #7 Record review of Resident #7, [AGE] year-old female, discharged from facility 7/14/23 (moved closer to family) last MDS dated [DATE] BIMS 6 (severely cognitively impaired). Medical Diagnosis Alzheimer (a neurodegenerative disease), Resident # 7 resided in facilities secured unit. Resident #12 Record review of Resident #12, [AGE] year-old female, MDS dated [DATE] BIMS 00 (severely cognitively impaired), Medical Diagnosis Alzheimer (a neurodegenerative disease), Resident #12 resides in facility secure unit. Record review of incident report dated 5/30/23 indicated as Resident #12 and Resident #7 passed each other in the hall on the secure unit at 3:45 pm, Resident #12 slapped Resident #7 on the left side of face. CNA A witnessed incident. CNA B stated no words were exchanged between residents before or after the incident. CNA B stated both residents kept walking down the hall as if nothing happened. CNA A reported incident to LVN A. LVN A assessed both residents, Resident #7 did not have any marks or redness on left side of face or injuries anywhere on face or body. Resident #12 had no injuries. LVN A stated neither Resident #7 or Resident #12 had any clue or was aware of any incident. LVN A reported incident to the DON, resident's physicians, and families. Interview on 8/9/23 at 11: 00 am, the DON stated she reported incident to HHSC on 5/30/23, and an Intake Investigation Worksheet was assigned to incident. The DON stated her investigation did not establish what caused the behavior of Resident #12 to slap Resident #7, neither resident had any history of aggression towards anyone or each other. Neither resident suffered injury or mental destress over incident. Both residents are non-interview able. The DON stated she provided in-service training to staff on 5/31/23, topics include Tips and Strategies for De-Escalating Aggressive, Hostile, or Violent Patients. The DON stated she has been submitting incidents to HHSC for several months due to not having a permanent Administrator, (facility has been using interim Administrators for the past several months). The DON stated she performed an investigation on the incident, but she must have forgotten to submit the PIR findings for the incident on 5/30/23, on form (3613-A) to HHSC. Record review of facility's Resident-to-Resident Altercations policy Revised 9/2022 indicated the following: 4. If two residents are involved in an altercation: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455968 If continuation sheet Page 2 of 3 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 455968 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Graham Oaks Care Center 1325 First St Graham, TX 76450 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 j. Report incidents, findings, and corrective measures to appropriate agencies as outlined in Level of Harm - Minimal harm or potential for actual harm Abuse, Neglect-Reporting, and Investigation Record review of facility's Abuse/Neglect Policy Revised 3/29/18 Residents Affected - Few Section F Investigation 3. G. Other pertinent information as available. The written report must be sent to HHSC no later than the Fifth working day after the initial report. The facility will use the designed state reporting form (3613-A). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455968 If continuation sheet Page 3 of 3