Inspection·September 9, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few gloves and attempted to re-direct Resident #12. She said Resident #12 continued to want to open the door and became increasingly agitated and started screaming. She said Resident #12 tried to move around her to exit the door and became combative. She tried to explain to Resident #12 that she could not go out of the unit because Resident #12 was positive for COVID-19. She said Resident #12 started spitting and kicking her. She said the facility staff nurse said Resident #12 had Sundowner's syndrome (condition in which a state of confusion worsens in the late afternoon and lasting into the night and is common in residents with Alzheimer's disease) and would become increasingly agitated in the afternoons and evenings. She said the facility staff nurse LVN E came into the COVID unit and took Resident #12 to her room. She said Resident #12 calmed down in her room, but soon after became agitated again. She said Resident #12 came back out and as she blocked the door, Resident #12 grabbed a pen and stabbed her with it in the back. She said Resident #12 tried to hit the CNA's with her walker. She said she felt this behavior was not normal for Resident #12 and called EMS due to Resident #12 having altered mental status. She said she asked other staff if this was normal and they said yes, but there were no notes or interventions about how to handle her behavior . She said Resident #12 likely bruised her arm when she was swinging her arms wildly in an attempt to leave the COVID unit. She said no one grabbed or caused the mark on Resident #12's arm. She said routine seemed to know how to handle Resident #12 better and without instructions or notes for interventions agency staff were not able to address Resident #12's behavior in the best way possible. In an interview on 09/09/2022 at 10:11 AM, the MDS NURSE said she was the manager on-call for 09/04/2022 and went to the facility after being notified by another charge nurse of Resident #12's behavior. She said there were no concerns for abuse of Resident #12 by any staff after investigating the incident. She said Resident #12 had a history of becoming agitated and would become verbally abusive towards staff and use racial slurs. She said the facility staff were familiar with her and would re-direct her when she became agitated. She said the agency staff on 09/04/2022 were unfamiliar with Resident #12 which likely caused her behavior to escalate. She said the behaviors were not on the care plan but should have been with interventions for how best to de-escalate Resident #12's behavior. In an interview on 09/09/2022 at 10:52 AM, LVN E stated she assisted agency staff with calming Resident #12 when Resident #12 wanted to leave the COVID unit. She put a gown on and took Resident #12 to her room. She said Resident #12 had a history of Sundowner's syndrome. She said Resident #12 would become agitated and confused and yell at staff. She said Resident #12 commonly used racial slurs when upset. She said they would re-direct her and give her a crossword puzzle to distract her. She said routine facility staff knew best how to handle her and agency staff were not as familiar with how to handle Resident #12's behavior. She said she thought this was included in Resident #12's care plan. In an interview on 09/09/2022 at 11:15 AM, LVN A stated Resident #12 had a history of becoming agitated and verbally abusive towards staff at times. She said they would re-direct and distract her when Resident #12 exhibited behaviors. She said Resident #12 was hard of hearing and if you wrote questions down for her to ask what was wrong it helped to distract Resident #12 and calm her. She said facility staff knew how to handle Resident #12 and de-escalate situations when Resident #12 was agitated. In an interview on 09/09/2022 at 12:05 PM, the ADON stated Resident #12 had a history of being triggered when made to do something she did not want to and would become verbally abusive towards staff and use racial slurs. She said this behavior should have been addressed in her care plan with effective interventions noted. She said the MDS NURSE was responsible for accurate completion of the care plan and would update Resident #12's care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675277 If continuation sheet Page 2 of 8 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 675277 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Care Inn of LA Grange 457 N Main St LA Grange, TX 78945 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility policy titled Care Plan-Resident dated October 2020 revealed in part .It is the policy of this home that staff must develop a comprehensive care plan to meet the needs of the resident .a. Must be measurable .b. Must be time-limited. List a target date for the resident to achieve the long-term goal .the care plan will be person centered to provide person centered care .a. Review CAA (Care Area Assessment) triggers on the MDS .the specific problem as well as the underlying cause should be listed .b. The care plan must be reviewed and revised (updated) at least every 90 days .b. The resident care plan must be started the day the resident is admitted and completed within seven days after the comprehensive assessment is completed . Event ID: Facility ID: 675277 If continuation sheet Page 3 of 8 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 675277 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Care Inn of LA Grange 457 N Main St LA Grange, TX 78945 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident received and the facility provided appealing options of similar nutritive value to residents who chose not to eat food that was initially served or who requested a different meal choice for one (Resident #37) of five residents reviewed for resident preferences and substitutes. The facility failed to ensure an alternative entrée with similar nutritive was available and offered to Resident #37 when he did not eat the meal he was served. This failure could place residents at risk for poor oral intake, weight loss, and poor quality of life. Findings included: Review of Resident #37's face sheet dated 09/09/2022 revealed Resident #37 to be a [AGE] year-old male admitted to the facility with the diagnoses of intractable pain from fusion of the lumbar portion of his spine, Type II Diabetes, hydronephrosis with renal and ureteral calculous obstruction (condition caused by a kidney or urethra stone which causes the buildup of urine in the urinary system) and depression. Review of Resident #37's admission MDS assessment dated [DATE] revealed Resident #37 had a BIMS score of 15 to indicate intact cognition. Resident #37 was not noted to require a mechanically altered or therapeutic diet. Resident #37 did not require assistance with eating. Review of Resident #37 Care plan dated 06/16/2022 revealed Resident #37 ate independently and did not require assistance from staff. In reference to Resident #37's nutritional status, he was ordered a regular diet with regular texture. The care plan noted that if Resident #37 should be served the regular diet and staff were to offer substitutes if less than 50% of his food was eaten and intake should be monitored. In an interview on 09/09/2022 at 11:30 AM, Resident #37 stated the food was pretty good at this facility and if he did not like what they were serving, he would order a sandwich. He said he used to receive health shakes three times a day when he was first admitted because he had lost weight while in the hospital for back surgery and intractable pain. He had gained weight since being admitted and since he ate his meals most of the time, the doctor said he could stop the health shakes. When asked if there were alternatives to eat besides a sandwich when he did not like the food, he said yes but it had to be ordered in advance. He said the staff can bring a sandwich at mealtime if he did not like the entrée. He said there was no other food served with the sandwich, and he was not offered additional food or supplements. He said he ate a sandwich last night for dinner because he did not like the food and there was no other food brought with the sandwich. He said he was not sure what would happen if he asked for additional food to go with the sandwich. He said has only received a sandwich as an alternative to meals. In an interview on 09/09/2022 at 11:40 AM, the DM stated if a resident did not like the food offered on the menu, they could order from the always available menu which would include soup and sandwich as a substitute for the main entrée. She said Resident #37 requested a sandwich sometimes if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675277 If continuation sheet Page 4 of 8 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 675277 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Care Inn of LA Grange 457 N Main St LA Grange, TX 78945 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few he did not like the food served. She said maybe twice per week he wanted a sandwich. She said the staff should have taken both soup and sandwich to him so the nutritive and calorie value would be similar to the main entrée served. She said it was not the facility policy to offer a nutrition supplement or health shake if intake was poor unless ordered by the doctor. She said they offer food first before a supplement. She said just eating a sandwich as a substitute for the main entrée would not have the same nutritive value as the main entrée. In an interview on 09/09/2022 at 11:50 AM, the RD stated if residents do not like the main entrée they could order from the always available menu. She said the choices from the always available menu would be of similar nutritive value as the main entrée. She said residents should be offered the substitute of their preference of similar nutritive value. She said she was not aware that Resident #37 was only receiving a sandwich when he ordered a substitute for his meal. She said Resident #37 should be offered additional food with the sandwich so that the nutritive value was like the main entrée to prevent weight loss. She stated Resident #37 had gained weight since admission but substituting only a sandwich could put him at risk for weight loss. In an interview on 09/09/2022 at 12:10 PM, the ADON stated the facility had alternative choices if a resident did not like the main entrée. She stated she was not aware that Resident #37 was not offered other food besides a sandwich when he did not like the main entrée. She stated a sandwich would not be of equal nutritive value as the main entrée. She stated they honor the resident's preference for a sandwich but should offer additional food with it like soup or crackers to increase the nutritive value to being similar to the main entrée. Review of the Dinner Menu dated 09/06/2022 revealed the main entrée to be a crab cake, broccoli rice casserole, parslied carrots, dinner roll, peach slices with milk and water with an approximate calorie content of 700 calories. Approximate calorie count of a sandwich would be 350-400 calories. Review of Alternate Food Choices and Substitutions and Honoring Preferences Policy dated 10/01/2018. An alternate entrée and vegetable will be offered at each meal. If a resident's preferences indicate they dislike the main meal, the alternate will be served unless the resident requests a substitution. Nursing staff will observe the residents at meal time. Any resident not eating will be offered the alternate meal or a substitute from the items available in the kitchen. The items offered must be compatible with any dietary restrictions or texture modifications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675277 If continuation sheet Page 5 of 8 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 675277 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Care Inn of LA Grange 457 N Main St LA Grange, TX 78945 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the ice machine #1 located in the dining room that provided ice for the dining room and all six of the resident hallways. The facility failed to clean and sanitize the kitchen ice machine which resulted in the ice machine having black mold growing on the interior right side of the ice bin. This failure could place the residents who used ice from the ice machine at risk of foodborne illness. Findings included: An observation on 09/07/2022 at 12:42 PM reflected ice machine #1 located in the dining room had a 12 inch by 18-inch patch of black mold on the interior right wall of the ice bin. In an interview on 09/07/2022 at 3:45 PM, the DM stated the kitchen staff complete weekly cleaning of the ice machine bin . She stated the maintenance director did any repairs or other required maintenance. She said the black mold built up over the course of the week and the facility has had repairman out to try to figure out why the black mold returns to the ice machine. She monitored the machine for cleanliness daily, but had not yet done so today. She said usually wiping it down weekly kept the black mold from building up in the machine. She said the black mold could expose residents to food borne illness which could result in nausea, vomiting, diarrhea and other health complications. She said they disposed of the ice in the machine and were using bagged ice until the machine made enough new ice. An observation on 09/08/2022 at 9:55 AM reflected during medication pass black flecks floated in the water at the bottom of the ice pitcher dated 09/08/2022. In an interview on 09/08/2022 at 9:56 AM, MA B stated she got new water this morning and the black flecks must have been in the ice. MA B did not know what the black flecks were caused by in the ice machine. She said she would get new water and ice for the residents as they could be exposed to food borne illness. An observation on 09/08/2022 at 10:35 AM reflected ice in the ice machine had black flecks in the ice. Observed ice scoop in ice scoop holder with black mold/mildew in the bottom of the scoop holder. In an interview on 09/08/2022 at 10:40 AM, the ADMIN stated he had seen the black flecks in the ice before and there was an ongoing issue with mold in the ice machine. He said they had multiple repairmen out to work on the machine and the problem with the black flecks returned. He said they would put the ice machine out of order and use bagged ice until the new ice machine was received . He said the scoop holder was not supposed to hold water and did not know how it built up mold in the bottom of the scoop holder. He said they would clean it thoroughly. He said exposure to the black mold could cause food borne illness in the residents. Review of Weekly Cleaning Schedule dated 07/17/2022 through 09/03/2022 revealed the ice machine was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675277 If continuation sheet Page 6 of 8 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 675277 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Care Inn of LA Grange 457 N Main St LA Grange, TX 78945 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 0812 Level of Harm - Minimal harm or potential for actual harm cleaned weekly on the following dates: 07/23/2022, 07/31/2022, 08/06/2022, 08/13/2022, 08/13/2022 and 08/28/2022. In an interview on 09/09/2022 at 10:00 AM, the ADMIN stated the facility had no policy or procedure regarding the ice machine cleaning and maintenance. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675277 If continuation sheet Page 7 of 8 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 675277 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Care Inn of LA Grange 457 N Main St LA Grange, TX 78945 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 0912 Level of Harm - Potential for minimal harm Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on interview and record review the facility failed to ensure that 49 of 49 resident rooms met the required square footage in that: Residents Affected - Many All 49 resident rooms were less than the required space of 80 square feet in multiple resident rooms or 100 square feet for single resident rooms. This included rooms 101, 102, 103, 104, 105, 106, 107, 108, 109, 201, 202, 203, 204, 205, 206, 207, 208, 209, 301, 302, 303, 304, 305, 306, 401, 402, 403, 404, 405, 406, 407, 501, 502, 503, 504, 505, 506, 507, 508, 509, 510, 601, 602, 603, 604, 605, 606, 607, 608. This failure could restrict the amount of resident care equipment and resident's personal effects that could be accommodated in these resident rooms, limit the ability of the to move about the room, decrease resident's quality of life. The findings were: In an interview on 09/07/2022 at 3:30 PM the ADMIN stated the facility had a waiver for room size and that it was the facility's intention to request a continuation of the waiver. Review of a previous waiver issued by HHSC revealed the waiver was granted for room sizes for all 49 resident use rooms. Review of the facility's CMS Form 672, Resident Census and Conditions of Residents, dated 09/07/2022, revealed a census of 44. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675277 If continuation sheet Page 8 of 8