Health inspection·October 10, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few pushed her into the bathroom after which the resident could not be viewed by the camera. Video clip #2 Resident #1 is not in view, but Hospitality Aide A is seen standing in the doorway of the bathroom and is heard stating I I can't get in there. I'm sorry. She turned toward the resident's room door which was closed, opened the door and stated: Let me get some help. She then left the room. The resident could be heard groaning and calling out help!. She was not in view of the camera and the clip ended. Record review of the nurses note dated 9/2/2025 11:34 PM reflected the following information: Note Text: BP-146/94. T-97.5. P-101. R-18.Resident had a fall. Location: Resident Bathroom Fall information: Assisted, Legs gave out, .Cognition / Behavior at Time of Event: Oriented / no problem,This nurse was notified by the Hospital Aide that she had assisted residents to the ground via a gait belt from sit to stand device. The Hospitality Aide was assisting the resident to bathroom and during the transfer to toilet, resident could not get bearings on her legs, and they gave out. No injuries noted at the time of assisted fall. The Resident #1 did not hit her head, alert and oriented x4. resident complained of left knee discomfort. Resident assisted to w/c from floor by 3 staff members and placed in bed. Will continue to monitor for delayed injuries. Appears and/or states to be in pain. Describes the pain as: Intermittent, Location of pain: left knee Pain relieving intervention used at this time: routine oxycodone.Initial Treatment/New Orders:Resident Statement: resident stated legs gave out trying to transfer from sit & stand to toiletName of MD/NP notified: Medical Director/Primary Care PhysicianDate/time of notification: 09/02/2025 9:00 PM.Name of RP notified: husband Date/time of notification: 09/02/2025 9:00 PM.Interventions in place prior to fall: Scheduled toileting program, x2 assist when toiletingInterventions initiated in response to fall: Scheduled toileting program, x2 assist with transfers9/3/2025 01:52 Transfer Notification Note Text: Resident #1 was transferred to a hospital on [DATE] 1:30 AM related to resident had assisted fall in bathroom and hurt left knee, swelling noted in left knee, unable to manage pain or get x-ray until business hours, resident request to be sent to ER. Record review of the Hospitality Aide's job description stated in part: Knowledge base - ability to record information, good communication skills, genuine care for and interest in the elderly, ability to comply with company safety policies, provide support to the nursing department by assisting with non-nursing tasks, including but not limited to bed making, passing water and ice, answering call lights and gathering supplies. The Hospitality aide job description was signed on 8/27/25 by Hospitality Aide A. Record review of the facility incident logs for the months of July, August, and September 2025, revealed no other injuries related to transfers. Record review of the facility policy Transfers from Chair to Bed stated the following in part: .A gait belt should be used for all transfers and the resident supported by holding the gait belt. Record review of Hospitality Aide A's employee file revealed she was not trained for transfer skills and competency checked until 9/11/25 after which she was allowed to come back to work. Record review of the facility Policy titled Abuse/Neglect revealed the following in part: The resident has the right to be free from abuse and neglect, misappropriation, of resident property and exploitation as defined in this subpart. Neglect is the failure of the facility, its employees, or services providers to provide goods, and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. During an interview and an observation on 10/1/25 at 11:35 AM Resident #1 was sitting up in her electric wheelchair in her room with her left leg elevated. She stated she was non weight bearing to her left leg because of the fracture and she had to be transferred with a Hoyer lift. Resident #1 stated she did persuade Hospitality Aide A to use the transfer device despite Hospitality Aide A telling her she did not know how to us the transfer device. She stated she persuaded her to use the device because it was easier for her but stated some of the girls didn't like to use the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455968 If continuation sheet Page 2 of 12 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 10/10/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few device because it was difficult to maneuver in her small bathroom and she slid off the edge of the seat. She stated her leg was caught between the lift and the wall and it hurt. She stated they had to get the assistance of Hospitality Aide B to get her off of the floor and LVN C watched. Hospitality Aide A did not come back to the room. During an interview with Hospitality Aide A on 10/3/25 at 6:00 PM Hospitality A stated she didn't know how to use the sit to stand equipment, but she answered Resident #1's call light and Resident #1 kept telling her she needed to urinate. Hospitality Aide A stated she knew Resident #1's call light had been on for about 20 minutes before she went into the room to answer it. She then stated they were shorthanded that evening and she had been assigned by LVN C to work as a floater in 3 different halls. Hospitality Aide A stated she knew there was no one around to assist at that time because no one else answered the call light. Hospitality Aide A stated Resident # 1 asked her to use the sit to stand machine to transfer her to the toilet in the bathroom, so she did it anyway, knowing that she was not supposed to do a transfer. Hospitality Aide A stated she assisted Resident #1 to the toilet but was unable to get her lined up over the toilet seat. Hospitality Aide A stated Resident #1 then said her legs were giving way and she was unable stand. Resident #1 then fell to the floor. Hospitality Aide A stated she was unable to use a gait belt to aid in the support of Resident #1. Hospitality Aide A stated she realized after the incident that she should not have done the transfer because she had not been trained and that she had no training on the use of the transfer device before the incident. Hospitality Aide A stated the facility then told Resident #1 the device would have to be taken home because it did not belong to the facility and there was no manual for its use. Hospitality Aide A stated she was suspended after the incident and was allowed to come back after 9 days when the facility completed their investigation and that is when they had the training and check off skills for her. During an interview with Hospitality Aide B on 10/10/25 at 6:15 PM he was called to Resident #1's room after the fall on 9/2/25 to get her off the floor. He stated her leg was between the machine and the wall of the bathroom and he was unable to use a gait belt to lift her off the floor. He stated he lifted her underneath her arms and put her back into her chair. He then returned to the memory care unit where he was stationed that night. Hospitality aide B stated he had no training on use of the device by the facility. During an interview with the Administrator on 10/3/25 at 10:00 AM, she stated she was not aware that staff were not trained on the sit-to-stand machine until after the incident. She stated she thought the machine belonged to the facility; and that the DON that was no longer employed with the facility had trained them. She stated the prior DON had been in charge of training of Hospitality Aides and following through to ensure staff complete training for all equipment used for transfers and that they were tested and competency checked before using the equipment and all skills were performed. The Administrator stated that after the incident and during the time of the facilities investigation of the incident, that there was no policy manual for the use of the sit- to-stand device. The administrator stated she did not know Hospitality Aide A was performing transfers without training and competency checks. She stated that her expectation was that a Hospitality Aide does not perform transfers and duties that were not included in their job description and for which they had not been trained appropriately. The Administrator then stated she expected the DON to be responsible for monitoring and education of all staff. Attempted to interview LVN C on 10/8/25 and again 10/9/25 (Charge Nurse) regarding the incident with Resident #1, but she replied by text to the Administrator stating she was in the hospital, and she was unable to interview. During an interview on 10/9/25 at 11:00 AM The Administrator stated she was no longer employed by the facility effective today 10/9/25. During an interview with the Director of Therapy on 10/3/25 at 10:30 AM he stated Resident #1 was a one-person transfer prior to her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455968 If continuation sheet Page 3 of 12 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 10/10/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few fall, but she was now a 2 person Hoyer lift due to the non-weight bearing status to her left leg and her therapy had been put on hold. He stated he communicated to the former DON that the sit-to-stand lift did not belong to the facility and there was no manual for the equipment. He stated the residents had not been checked off to use the device and the staff were not trained. He stated he made it clear to the former DON that he was not qualified to do the training, because the use of the equipment was not a part of his curriculum in therapy school. He stated he assumed everyone in the facility knew the device was used by the resident because it was in her room and it was a large piece of equipment and hard to miss. He stated he did not recall the date that he relayed this information to the former DON, but he asked her to ensure staff did not use the device. During an interview with the former DON on 10/3/25 at 4:16 PM she stated her last day at the facility was 8/15/25. She stated she did not remember the Director of Therapy telling her that the staff should not use the device. She stated she did know that the device was being used by staff to do the transfers of Resident #1 without training and competency checks. During an interview with the Medical Director/Primary Physician on 10/6/25 at 4:00 PM he stated his expectation was that residents be transferred by staff that had been trained and the equipment used had been safely checked. Review of Hospitality Aide A's training record reflected that she had completed training on Position and Transfer Techniques and fall prevention on 9 /11/25. She had also signed an acknowledgment on 10/3/25 that she was to follow the resident's care plan to know who required a Hoyer lift or who was to be lifted by two people. During an interview on 10/3/25 with Hospitality Aide A, she stated if there were any questions about how a resident was to be transferred, she knew she was to clarify this with the nurse.During an Observation on 10/4/25 at 1:30 PM Hospitality Aide B and CNA 1 perform a Hoyer lift on 10/4/25 at 1:30 PM using 2 people on Resident #4 and proper procedure and all all-safety rules were followed, and no incidents were noted. In an interview with the Administrator on 10/8/25 at 9:00 A.M., she stated after the incident on 9/3/25 they immediately completed the following corrections/interventions. The facility was evaluated to be in past noncompliance based on the corrections implemented prior to entrance. Review of the Plan reflected: 1. Self-reporting protocol initiated on 9/3/25 and dated 9/3/23.2. Reported incident to the State within 2 hours of incident 9/3/25.3. Known perpetrator (Hospitality Aide A) suspended immediately pending investigation.4. Care plan for Resident #1 updated immediately and revised for injury.5. Skin assessments on all non-verbal residents and Safe Surveys of interviewable residents on halls A, B, C, D, were completed on 9/3/25 and 9/4/25.6. Interviews with staff members regarding whether they have seen a fellow staff member act in an abusive or neglectful manner toward a resident was completed on 9/3/257. Abuse and neglect Inservices started with all staff on 9/3/258. Ad HOC QAPI meeting held 9/3/25 for Inappropriate transfer by untrained staff.6. Audited all resident's Kardex/care plan on 09/3/25 to ensure all resident's level of care was updated and accurate.7. Educated and validated all staff understood the use of the Kardex/care plan system on 09/3/258. Review plan in QAPI monthly until resolved. Completed risk management entry 9/3/259. Medical director notified of this plan on 9/3/25 by the Administrator.10. The DON and Admin will monitor for potential neglect by reviewing incidents in stand up daily 9/3/2511. Monitor at least 10 of the following ADL Actions each week to ensure that the proper number of staff is providing assistance: bathing, bed mobility, transferring, walking initiated 9/3/25All monitoring above will continue for at least 4 weeks. The QAPI committee will review the findings and make revisions to the plan, as necessary. Verification 10/9/25 :Correction #1:In an Interview on 10/9/25 at 11:00 AM the Administrator stated that she received a call from the Charge Nurse notifying her of Resident #1's fall 0n 92/25. The resident was assessed and did not complain immediately. She did begin to complain of pain and the charge (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455968 If continuation sheet Page 4 of 12 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 10/10/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few nurse notified her that the resident was requesting to go to the hospital. She was sent to the hospital and diagnosed with a fracture on her left knee. During the course of the investigation the administrator discovered that the resident was transferred by Hospitality Aide A that was performing duties such as transfer, that were not in her signed job description and was doing so without appropriate training on safety and operation. She stated she immediately filed a self-report and suspended the perpetrator pending the results of the investigation. She was informed by therapy staff that the mechanical lift device was not owned by the facility and no one in the facility had been trained to use the device. She stated she could see by viewing the video that Hospitality Aide A did perform the transfer with the device, and this was not a duty for which she was currently trained to do according to her job description. She notified Resident #1's family of the need to remove the device from the resident's room. The sit to stand device was no longer in the building as of 9/3/25. Record review of the facility reporting protocol template indicated all areas of the self-reporting protocol had been completed, dated, and signed by the staff. Correction #2. Record review of the nurses note dated 9/2/2025 11:34 PM Note Text: BP-146/94. T-97.5. P-101. R-18.Resident had a fall. Location: Resident Bathroom Fall information: Assisted, Legs gave out, .Cognition / Behavior at Time of Event: Oriented / no problem,This nurse was notified by the Hospital Aide that she had assisted residents to the ground via a gait belt from sit to stand device. The Hospitality Aide was assisting the resident to bathroom and during the transfer to toilet, resident could not get bearings on her legs, and they gave out. No injuries noted at the time of assisted fall. The Resident #1 did not hit her head, alert and oriented x4. resident complained of left knee discomfort. Resident assisted to w/c from floor by 3 staff members and placed in bed. Will continue to monitor for delayed injuries. Appears and/or states to be in pain. Describes the pain as: Intermittent, Location of pain: left knee Pain relieving intervention used at this time: routine oxycodone.Initial Treatment/New Orders:Resident Statement: resident stated legs gave out trying to transfer from sit & stand to toiletName of MD/NP notified: Medical Director/Primary Care PhysicianDate/time of notification: 09/02/2025 9:00 PM.Name of RP notified: husband Date/time of notification: 09/02/2025 9:00 PM.Interventions in place prior to fall: Scheduled toileting program, x2 assist when toiletingInterventions initiated in response to fall: Scheduled toileting program, x2 assist with transfers9/3/2025 01:52 Transfer Notification Note Text: Resident #1 was transferred to a hospital on [DATE] 1:30 AM related to resident had assisted fall in bathroom and hurt left knee, swelling noted in left knee, unable to manage pain or get x-ray until business hours, resident request to be sent to ER. Correction #3Record review of the Ad Hoc QAPI meeting revealed the meeting was conducted on 9/3/25 with the following members attending: Medical Director, Administrator, DON, ADON #1, ADON #2, MDS Nurse #1, MDS Director 1, MDS Director #2, Social Worker, Medical Records, Medical Director. Correction #4Record review of the Employee Disciplinary Report dated 9/4/25 revealed the Hospitality Aide A was suspended for investigation of Neglect and the improper transfer. Correction #5Record review of Skin assessments on all non-verbal residents and Safe Surveys of interviewable residents on halls A, B, C, D, completed on 9/3/25 and 9/4/25. Record review of Residents #5, #6 safe survey forms and interviews with Residents #2, #3, and #4 from 2 PM to 4 Pm on 10/9 /24 confirmed that they did feel safe in the facility, and all stated they were transferred properly. During interviews with Residents #2, # 3, #4, #5, and #6 from 2 PM to 4 PM they stated they could tell the difference between the Nurse's Aide, Hospitality Aides and Certified CNAs by their name badge. Correction #6Reviewed the Abuse and Neglect inservice signature page and content of training dated 9/3/25. All facility staff had been trained on abuse and neglect Immediately after the incident with Resident #1 before they were allowed to return to work. Correction #7 Interviews (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455968 If continuation sheet Page 5 of 12 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 10/10/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete with 10 staff members Hospitality Aides A, B, C, K, E, D, F, G, H, I, J (formerly titled Hospitality aides but now classified as Nurses' Aides) between 2:00 PM and 4:00 PM on 10/9/25 reflected that they all attended a training skills lab on 9/3/25 and competed competency checks on 9/11/25. They stated hey were trained on Abuse and Neglect, Safe Transfers, an checked off on the Hoyer lift. Hospitality Aides A, B, C, K, E, D, F, G, H, I and J stated they were not allowed to operate the hydraulic controls and must transfer a mechanical lift with 2 people. Observed Hospitality Aide B and CNA 1 perform a Hoyer lift on 10/4/25 at 1:30 PM using 2 people on Resident #4 and proper procedure and all all-safety rules were followed, and no incidents were noted. Correction #8Reviewed QAPI minutes for meeting last held 10.3.25. Reviewed PIP dated 9/3/25 for incident. Meeting attended by medical director. Signed on 10/3/25. Correction # 9Interview with the Medical Director on 10/6/25 at 4:00 PM verified that he had been notified of the incident and the PIP on 9/3/25. Correction #10 Reviewed monitoring by the facility of ADL assistance initiated on 9/3/25 revealed that the monitoring was complete and current with evidence of monitoring from 9/3/25 to 10/9/25. Monitoring continues daily at the time of exit. During an Interview with the Administrator on 10/10/25 at 8:00 AM stated she only had 1 hospitality aide left in the building as of 10/9/25. She stated everyone else had completed training and skills checks and were ready to test. She stated scheduling was in process with herself and the new DON monitoring compliance During an Interview with Resident #1 on 10/9/25 at 4:00 PM she stated she had not been transferred by staff other than CNAs, and LVN, and that no Hospitality Aides had transferred her since the incident. She stated they always use 2 people to transfer. She stated she was transferred by the Hoyer lift and that her family member was asked by the administrator to remove the sit to stand device from the building. During an Interview with the current DON and the RNC on 10/9/25 at 4:10 PM both stated all Hospitality aides were checked off on transfer skills as of 9/19/25. Interviews with 7 Nurses' Aides (B, D, E, F, G, H, I, J) and one Hospitality Aide K on 10/9/25 between 9:00 and 10:00 AM were able to state their job description and duties they were allowed to perform. They stated they would go to the Kardex in the point of care to make sure what kind of care they needed. Hospitality Aide K stated she was told by the administrator that she cannot work on the floor until she passes her Texas Nurse's Aide Training requirement online and supervised clinical with competency checks. During Interviews with resident numbers 1,3,4,5,6,7 and 8 on 10/9/25 between 11:00 AM and 1:00 PM all stated that that they were transferred appropriately and had no transfer related incidents. Residents #1, #7 and #4 stated that were transferred by a Hoyer lift by two people, and never just by one person. Residents stated they could tell if a resident was a Hospitality Aide or CNA or a Nurse's Aide by looking at their employee's name badge. They stated Hospitality aides were not allowed to transfer residents. Record reviews of skills checklist and CNA online training revealed certificates of training and skills check lists for Nurses' Aides B, E, F, G, H, I, J and one Hospitality Aide K were in their employee files and dated before entrance. During Interviews on 10/9/25 between 11:00 and 1:00 PM Nurses' Aides B, D, E, F, G, H, I, J and one Hospitality Aide K stated they signed a nurse's aide job description stating their duties and name tags were updated to reflect their current job duties. Record review of Resident #1's care plan reflected that she was a Hoyer lift as of 9/3/25. Record review of Resident #'s 1, 2, 3, 4, 5, 6, and 7's care plan and Kardex reflected accuracy. Event ID: Facility ID: 455968 If continuation sheet Page 6 of 12 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 10/10/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure 1 (Resident #1) of 8 residents reviewed for accident hazards were free from accident hazards in their environment. The facility failed to ensure Resident # 1's received adequate supervision and assistive devices to prevent accidents. The lift used by facility staff was not an adequate assistive device since there was no manual for proper staff training and the device was the personal property of Resident #1. This resulted in a fall during a transfer in which Resident #1 received a fracture on her left knee on 9/3/25. The noncompliance was identified as PNC. The IJ began on 9/2/25 and ended on 9/3/25. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk for serious injuries, a decline in the resident's condition, hospitalization, or death. Findings included: Record review of Resident #1's admission Sheet, not dated, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her active diagnoses included Paraplegia (paralysis that affects the legs and not the arms), muscle weakness, unsteadiness on feet, osteomyelitis of vertebrate, and pain in thoracic spine. Record review of Resident #1's Annual MDS dated [DATE] reflected Resident #1 had a BIMS score of 15 (cognitively intact) and impaired range of motion in both lower extremities and section GG documented Resident #1 required partial to moderate assistance to transfer. Record review of Resident #1's comprehensive care plan, dated 7/14/25, reflected that she had a self-care performance deficit and required 1 staff to reposition and turn in bed, and to transfer from bed to chair. A revision of the care plan on 7/15/24 indicated that she used a sit to stand device, and it was discontinued on 9/3/25 Review of the Provider Investigation report dated 9/3/25 revealed: Resident had a fall during sit to stand transfer to the bathroom, resulting in left knee fracture . The Hospitality Aide that was assisting Resident #1 in the sit to stand transfer to the toilet was not trained or oriented to the sit to stand machine. The resident was sent to the emergency room for evaluation and pain medication was administered as ordered and as needed. There were no other negative findings at this time. Record review of a radiology report for Resident #1 dated 9/3/25 documented: There is a cortical discontinuity (interruption or fracture in the hard, dense, outer layer of bone that makes up most of the skeleton) in the lateral aspect of the left medial femoral condyle (the rounded, smooth end of the thigh bone that forms part of the knee joint), suggesting a fracture. Record review of the video evidence (Clip #1) date 9/2/25 at 6:56 PM provided by Resident #1 from her personal monitoring device located in her room, revealed Resident #1 was transferred by the Hospitality Aide A on 9/2/25 using her personal transfer equipment. The hospitality aide could not be heard in the video stating to Resident #1 that she had never used the sit to stand transfer device to perform a transfer. Resident #1 could be heard stating you have to learn when you're young. The Resident #1 is seen sitting on the transfer device while Hospitality Aide A pushed her into the bathroom after which the resident could not be viewed by the camera. Video clip #2 - Resident #1 is not in view, but Hospitality Aide A is seen standing in the doorway of the bathroom and is heard stating I I can't get in there. I'm sorry. She turned toward the resident's room door which was closed, opened the door and stated: Let me get some help. She then left the room. The resident could be heard groaning and calling out help!. She was not in view of the camera and the clip ended. Record review of the nurses note dated 9/2/2025 11:34 PM Note Text: BP-146/94. T-97.5. P-101. R-18.Resident had a fall. Location: Resident Bathroom Fall information: Assisted, Legs gave out, .Cognition / Behavior at Time of Event: Oriented / no problem,This nurse was notified by the Hospital Aide that she had assisted residents to the ground via a gait belt from sit to stand device. The Hospitality Aide was assisting the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455968 If continuation sheet Page 7 of 12 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 10/10/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few resident to bathroom and during the transfer to toilet, resident could not get bearings on her legs, and they gave out. No injuries noted at the time of assisted fall. The Resident #1 did not hit her head, alert and oriented x4. resident complained of left knee discomfort. Resident assisted to w/c from floor by 3 staff members and placed in bed. Will continue to monitor for delayed injuries. Appears and/or states to be in pain. Describes the pain as: Intermittent, Location of pain: left knee Pain relieving intervention used at this time: routine oxycodone.Initial Treatment/New Orders:Resident Statement: resident stated legs gave out trying to transfer from sit & stand to toiletName of MD/NP notified: Medical Director/Primary Care PhysicianDate/time of notification: 09/02/2025 9:00 PM.Name of RP notified: husband Date/time of notification: 09/02/2025 9:00 PM.Interventions in place prior to fall: Scheduled toileting program, x2 assist when toiletingInterventions initiated in response to fall: Scheduled toileting program, x2 assist with transfers9/3/2025 01:52 Transfer Notification Note Text: Resident #1 was transferred to a hospital on [DATE] 1:30 AM related to resident had assisted fall in bathroom and hurt left knee, swelling noted in left knee, unable to manage pain or get x-ray until business hours, resident request to be sent to ER.Record review of the Hospitality Aide's job description stated in part: Knowledge base - ability to record information, good communication skills, genuine care for and interest in the elderly, ability to comply with company safety policies, provide support to the nursing department by assisting with non-nursing tasks, including but not limited to bed making, passing water and ice, answering call lights and gathering supplies. The Hospitality aide job description was signed on 8/27/25 by Hospitality Aide A. Record review of the facility incident logs for the months of July, August, and September 2025, revealed no other injuries related to transfers. Record review of the facility policy Transfers from Chair to Bed stated the following in part: .A gait belt should be used for all transfers and the resident supported by holding the gait belt. Record review of Hospitality Aide A's employee file revealed she was not trained for transfer skills and competency checked until 9/11/25 after which she was allowed to come back to work. During an interview and an observation on 10/1/25 at 11:35 AM Resident #1 was sitting up in her electric wheelchair in her room with her left leg elevated. She stated she was non weight bearing to her left leg because of the fracture and she had to be transferred with a Hoyer lift. Resident #1 stated she did persuade Hospitality Aide A to use the transfer device despite Hospitality Aide A telling her she did not know how to us the transfer device. She stated she persuaded her to use the device because it was easier for her but stated some of the girls didn't like to use the device because it was difficult to maneuver in her small bathroom and she slid off the edge of the seat. She stated her leg was caught between the lift and the wall and it hurt. She stated they had to get the assistance of Hospitality Aide B to get her off of the floor and LVN C watched. Hospitality Aide A did not come back to the room. During an interview with Hospitality Aide A on 10/3/25 at 6:00 PM Hospitality A stated she didn't know how to use the sit to stand equipment, but she answered Resident #1's call light and Resident #1 kept telling her she needed to urinate. Hospitality Aide A stated she knew Resident #1's call light had been on for about 20 minutes before she went into the room to answer it. She then stated they were shorthanded that evening and she had been assigned by LVN C to work as a floater in 3 different halls. Hospitality Aide A stated she knew there was no one around to assist at that time because no one else answered the call light. Hospitality Aide A stated Resident # 1 asked her to use the sit to stand machine to transfer her to the toilet in the bathroom, so she did it anyway, knowing that she was not supposed to do a transfer. Hospitality Aide A stated she assisted Resident #1 to the toilet but was unable to get her lined up over the toilet seat. Hospitality Aide A stated Resident #1 then said her legs were giving way and she was unable stand. Resident #1 then fell (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455968 If continuation sheet Page 8 of 12 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 10/10/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few to the floor. Hospitality Aide A stated she was unable to use a gait belt to aid in the support of Resident #1. Hospitality Aide A stated she realized after the incident that she should not have done the transfer because she had not been trained and that she had no training on the use of the transfer device before the incident. Hospitality Aide A stated the facility then told Resident #1 the device would have to be taken home because it did not belong to the facility and there was no manual for its use. Hospitality Aide A stated she was suspended after the incident and was allowed to come back after 9 days when the facility completed their investigation and that is when they had the training and check off skills for her. During an interview with Hospitality Aide B on 10/10/25 at 6:15 PM he was called to Resident #1's room after the fall on 9/2/25 to get her off the floor. He stated her leg was between the machine and the wall of the bathroom and he was unable to use a gait belt to lift her off the floor. He stated he lifted her underneath her arms and put her back into her chair. He then returned to the memory care unit where he was stationed that night. Hospitality aide B stated he had no training on use of the device by the facility. During an interview with the Administrator on 10/3/25 at 10:00 AM, she stated she was not aware that staff were not trained on the sit-to-stand machine until after the incident. She stated she thought the machine belonged to the facility; and that the DON that was no longer employed with the facility had trained them. She stated the prior DON had been in charge of training of Hospitality Aides and following through to ensure staff complete training for all equipment used for transfers and that they were tested and competency checked before using the equipment and all skills were performed. The Administrator stated that after the incident and during the time of the facilities investigation of the incident, that there was no policy manual for the use of the sit- to-stand device. The administrator stated she did not know Hospitality Aide A was performing transfers without training and competency checks. She stated that her expectation was that a Hospitality Aide does not perform transfers and duties that were not included in their job description and for which they had not been trained appropriately. The Administrator then stated she expected the DON to be responsible for monitoring and education of all staff. Attempted to interview LVN C on 10/8/25 and again 10/9/25 (Charge Nurse) regarding the incident with Resident #1, but she replied by text to the Administrator stating she was in the hospital, and she was unable to interview. During an interview on 10/9/25 at 11:00 AM The Administrator stated she was no longer employed by the facility effective today 10/9/25. During an interview with the Director of Therapy on 10/3/25 at 10:30 AM he stated Resident #1 was a one-person transfer prior to her fall, but she was now a 2 person Hoyer lift due to the non-weight bearing status to her left leg and her therapy had been put on hold. He stated he communicated to the former DON that the sit-to-stand lift did not belong to the facility and there was no manual for the equipment. He stated the residents had not been checked off to use the device and the staff were not trained. He stated he made it clear to the former DON that he was not qualified to do the training, because the use of the equipment was not a part of his curriculum in therapy school. He stated he assumed everyone in the facility knew the device was used by the resident because it was in her room and it was a large piece of equipment and hard to miss. He stated he did not recall the date that he relayed this information to the former DON, but he asked her to ensure staff did not use the device. During an interview with the former DON on 10/3/25 at 4:16 PM she stated her last day at the facility was 8/15/25. She stated she did not remember the Director of Therapy telling her that the staff should not use the device. She stated she did know that the device was being used by staff to do the transfers of Resident #1 without training and competency checks. During an interview with the Medical Director/Primary Physician on 10/6/25 at 4:00 PM he stated his expectation was that residents be transferred by staff that had been trained and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455968 If continuation sheet Page 9 of 12 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 10/10/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the equipment used had been safely checked. Review of Hospitality Aide A's training record reflected that she had completed training on Position and Transfer Techniques and fall prevention on 9 /11/25. She had also signed an acknowledgment on 10/3/25 that she was to follow the resident's care plan to know who required a Hoyer lift or who was to be lifted by two people. During an interview on 10/3/25 with Hospitality Aide A, she stated if there were any questions about how a resident was to be transferred, she knew she was to clarify this with the nurse.Observed Hospitality Aide B and CNA 1 perform a Hoyer lift on 10/4/25 at 1:30 PM using 2 people on Resident #4 and proper procedure and all all-safety rules were followed, and no incidents were noted. In an interview with the Administrator on 10/8/25 at 9:00 A.M., she stated after the incident on 9/3/25 they immediately completed the following corrections/interventions. The facility was evaluated to be in past noncompliance based on the corrections implemented prior to entrance. Review of the Plan reflected: 1. Self-reporting protocol initiated on 9/3/25 and dated 9/3/25 by the Administrator . 2. Reported incident to the State within 2 hours of incident 9/3/25.3. Known perpetrator (Hospitality Aide A) suspended immediately pending investigation.4. Care plan for Resident #1 updated immediately and revised for injury.5. Skin assessments on all non-verbal residents and Safe Surveys of interviewable residents on halls A, B, C, D, were completed on 9/3/25 and 9/4/25.6. Interviews with staff members regarding whether they have seen a fellow staff member act in an abusive or neglectful manner toward a resident was completed on 9/3/257. Abuse and neglect Inservices started with all staff on 9/3/258. Ad HOC QAPI meeting held 9/3/25 for Inappropriate transfer by untrained staff.6. Audited all resident's Kardex/care plan on 09/3/25 to ensure all resident's level of care was updated and accurate.7. Educated and validated all staff understood the use of the Kardex/care plan system on 09/3/258. Review plan in QAPI monthly until resolved. Completed risk management entry 9/3/259. Medical director notified of this plan on 9/3/25 by the Administrator.10. The DON and Admin will monitor for potential neglect by reviewing incidents in stand up daily 9/3/2511. Monitor at least 10 of the following ADL Actions each week to ensure that the proper number of staff is providing assistance: bathing, bed mobility, transferring, walking initiated 9/3/25All monitoring above will continue for at least 4 weeks. The QAPI committee will review the findings and make revisions to the plan, as necessary. Verification 10/9/25 :Correction #1:In an Interview on 10/9/25 at 11:00 AM the Administrator stated that she received a call from the Charge Nurse notifying her of Resident #1's fall 0n 92/25. The resident was assessed and did not complain immediately. She did begin to complain of pain and the charge nurse notified her that the resident was requesting to go to the hospital. She was sent to the hospital and diagnosed with a fracture on her left knee. During the course of the investigation the administrator discovered that the resident was transferred by Hospitality Aide A that was performing duties such as transfer, that were not in her signed job description and was doing so without appropriate training on safety and operation. She stated she immediately filed a self-report and suspended the perpetrator pending the results of the investigation. She was informed by therapy staff that the mechanical lift device was not owned by the facility and no one in the facility had been trained to use the device. She stated she could see by viewing the video that Hospitality Aide A did perform the transfer with the device, and this was not a duty for which she was currently trained to do according to her job description. She notified Resident #1's family of the need to remove the device from the resident's room. The sit to stand device was no longer in the building as of 9/3/25. Record review of the facility reporting protocol template indicated all areas of the self-reporting protocol had been completed, dated, and signed by the staff. Correction #2. Record review of the nurses note dated 9/2/2025 11:34 PM Note Text: BP-146/94. T-97.5. P-101. R-18.Resident had a fall. Location: Resident Bathroom Fall information: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455968 If continuation sheet Page 10 of 12 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 10/10/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Assisted, Legs gave out, .Cognition / Behavior at Time of Event: Oriented / no problem,This nurse was notified by the Hospital Aide that she had assisted residents to the ground via a gait belt from sit to stand device. The Hospitality Aide was assisting the resident to bathroom and during the transfer to toilet, resident could not get bearings on her legs, and they gave out. No injuries noted at the time of assisted fall. The Resident #1 did not hit her head, alert and oriented x4. resident complained of left knee discomfort. Resident assisted to w/c from floor by 3 staff members and placed in bed. Will continue to monitor for delayed injuries. Appears and/or states to be in pain. Describes the pain as: Intermittent, Location of pain: left knee Pain relieving intervention used at this time: routine oxycodone.Initial Treatment/New Orders:Resident Statement: resident stated legs gave out trying to transfer from sit & stand to toiletName of MD/NP notified: Medical Director/Primary Care PhysicianDate/time of notification: 09/02/2025 9:00 PM.Name of RP notified: husband Date/time of notification: 09/02/2025 9:00 PM.Interventions in place prior to fall: Scheduled toileting program, x2 assist when toiletingInterventions initiated in response to fall: Scheduled toileting program, x2 assist with transfers9/3/2025 01:52 Transfer Notification Note Text: Resident #1 was transferred to a hospital on [DATE] 1:30 AM related to resident had assisted fall in bathroom and hurt left knee, swelling noted in left knee, unable to manage pain or get x-ray until business hours, resident request to be sent to ER. Correction #3Record review of the Ad Hoc QAPI meeting revealed the meeting was conducted on 9/3/25 with the following members attending: Medical Director, Administrator, DON, ADON #1, ADON #2, MDS Nurse #1, MDS Director 1, MDS Director #2, Social Worker, Medical Records, Medical Director. Correction #4Record review of the Employee Disciplinary Report dated 9/4/25 revealed the Hospitality Aide A was suspended for investigation of Neglect and the improper transfer. Correction #5Record review of Skin assessments on all non-verbal residents and Safe Surveys of interviewable residents on halls A, B, C, D, completed on 9/3/25 and 9/4/25. Record review of Residents #5, #6 safe survey forms and interviews with Residents #2, #3, and #4 from 2 PM to 4 Pm on 10/9 /24 confirmed that they did feel safe in the facility, and all stated they were transferred properly. During interviews with Residents #2, # 3, #4, #5, and #6 from 2 PM to 4 PM they stated they could tell the difference between the Nurse's Aide, Hospitality Aides and Certified CNAs by their name badge. Correction #7 Interviews with 10 staff members Hospitality Aides A, B, C, K, E, D, F, G, H, I, J (formerly titled Hospitality aides but now classified as Nurses' Aides) between 2:00 PM and 4:00 PM on 10/9/25 reflected that they all attended a training skills lab on 9/3/25 and competed competency checks on 9/11/25. They stated hey were trained on Abuse and Neglect, Safe Transfers, an checked off on the Hoyer lift. Hospitality Aides A, B, C, K, E, D, F, G, H, I and J stated they were not allowed to operate the hydraulic controls and must transfer a mechanical lift with 2 people. Observed Hospitality Aide B and CNA 1 perform a Hoyer lift on 10/4/25 at 1:30 PM using 2 people on Resident #4 and proper procedure and all all-safety rules were followed, and no incidents were noted. Correction #8Reviewed QAPI minutes for meeting last held 10.3.25. Reviewed PIP dated 9/3/25 for incident. Meeting attended by medical director. Signed on 10/3/25. Correction # 9Interview with the Medical Director on 10/6/25 at 4:00 PM verified that he had been notified of the incident and the PIP on 9/3/25. Correction #10 Reviewed monitoring by the facility of ADL assistance initiated on 9/3/25 revealed that the monitoring was complete and current with evidence of monitoring from 9/3/25 to 10/9/25. Monitoring continues daily at the time of exit. During an Interview with the Administrator on 10/10/25 at 8:00 AM stated she only had 1 hospitality aide left in the building as of 10/9/25. She stated everyone else had completed training and skills checks and were ready to test. She stated scheduling was in process with herself and the new DON monitoring compliance During an Interview with Resident #1 on 10/9/25 at 4:00 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455968 If continuation sheet Page 11 of 12 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 10/10/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete PM she stated she had not been transferred by staff other than CNAs, and LVN, and that no Hospitality Aides had transferred her since the incident. She stated they always use 2 people to transfer. She stated she was transferred by the Hoyer lift and that her family member was asked by the administrator to remove the sit to stand device from the building. During an Interview with the current DON and the RNC on 10/9/25 at 4:10 PM both stated all Hospitality aides were checked off on transfer skills as of 9/19/25. Interviews with 7 Nurses' Aides (B, D, E, F, G, H, I, J) and one Hospitality Aide K on 10/9/25 between 9:00 and 10:00 AM were able to state their job description and duties they were allowed to perform. They stated they would go to the Kardex in the point of care to make sure what kind of care they needed. Hospitality Aide K stated she was told by the administrator that she cannot work on the floor until she passes her Texas Nurse's Aide Training requirement online and supervised clinical with competency checks. During Interviews with resident numbers 1,3,4,5,6,7 and 8 on 10/9/25 between 11:00 AM and 1:00 PM all stated that that they were transferred appropriately and had no transfer related incidents. Residents #1, #7 and #4 stated that were transferred by a Hoyer lift by two people, and never just by one person. Residents stated they could tell if a resident was a Hospitality Aide or CNA or a Nurse's Aide by looking at their employee's name badge. They stated Hospitality aides were not allowed to transfer residents. Record reviews of skills checklist and CNA online training revealed certificates of training and skills check lists for Nurses' Aides B, E, F, G, H, I, J and one Hospitality Aide K were in their employee files and dated before entrance. During Interviews on 10/9/25 between 11:00 and 1:00 PM Nurses' Aides B, D, E, F, G, H, I, J and one Hospitality Aide K stated they signed a nurse's aide job description stating their duties and name tags were updated to reflect their current job duties. Record review of Resident #1's care plan reflected that she was a Hoyer lift as of 9/3/25. Record review of Resident #'s 1, 2, 3, 4, 5, 6, and 7's care plan and Kardex reflected accuracy. Event ID: Facility ID: 455968 If continuation sheet Page 12 of 12