Inspection·October 12, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm A record review of Resident #36's face sheet dated 10/12/2023 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of chronic kidney disease, muscle wasting and atrophy (muscle loss), muscle weakness, reduced mobility, hypertension (high blood pressure), anemia (blood disorder), schizophrenia (mental disorder), mild intellectual disabilities, glaucoma (eye disease leading to vision loss) and major depressive disorder (depression). Residents Affected - Some A record review of Resident #36's MDS assessment dated [DATE] reflected a BIMS of 15, which indicated intact cognition. A record review of Resident #36's care plan last revised on 10/03/2023 reflected he had impaired visual function and was at risk for falls. Interventions included staff were to keep Resident #36's call light within reach at all times. During an observation and interview on 10/10/2023 at 4:12 p.m., Resident #32 was observed lying in bed. Observed Resident #32's call light to be wrapped around itself in a circular direction and hung on the wall. Resident #32 stated he knew how to use the call button but he could not reach it. During an observation and interview on 10/10/2023 at 4:24 p.m., MA C stated no Resident #32's call light was not within reach, she did not know who had put it up there, and I can't control where people put the call light. Observed MA C unwrap Resident #32's call light as she placed it within reach of the resident. During an observation and interview on 10/12/2023 at 9:19 a.m., Resident #36 was observed lying in bed and his call light was on the floor. Resident #36 stated I can't reach it and asked if the surveyor could pick it up for him. Resident #36 said the call light had been on the floor all night. During an observation and interview on 10/12/2023 at 9:27 a.m., Resident #19 was observed lying in bed and her call light was on the floor. Resident #19 asked if the surveyor could pick it up for her. During an interview on 10/12/2023 at 9:29 a.m., CNA A stated both Resident #19 and Resident #36 knew how to use the call light and used it. During an interview on 10/12/2023 at 9:32 a.m., Resident #19 stated she did not know how long the call light had been on the floor but that her hands were sore. During an observation and interview on 10/12/2023 at 9:33 a.m., CNA A stated no that Resident #19 could not reach her call light and it's on the floor. Observed that CNA A asked Resident #19 why her call light was on the floor and Resident #19 told CNA A she needed some kind of fastener for the light but that she would stick it under her pillow for now. During an interview on 10/12/2023 at 9:34 a.m., CNA A stated Resident #19 did not have a clip on her call light. During an interview on 10/12/2023 at 4:14 p.m., the ADON stated the facility's policy on call lights included making sure they were in reach. The ADON stated CNAs monitored to ensure call lights were in reach and nurse managers rounded to monitor CNAs. The ADON stated staff were trained on call light placement via in-services and through verbal one on one trainings. The ADON stated yeah that staff had been trained on call light placement and said, I talk to staff all the time. The ADON stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675277 If continuation sheet Page 2 of 9 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 10/12/2023 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 0558 if call lights were not in reach, residents would not be able to ask for help. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/12/2023 at 4:55 p.m., the Administrator stated the facility's policy on call lights was for them to be at bedside. The Administrator stated CNAs monitored to ensure they were within reach and regarding how CNAs were monitored, it's a facility effort. The Administrator stated housekeepers and department head monitored through Ambassador Rounds-the Administrator explained this meant rounding on rooms. The Administrator stated staff had been trained on call light placement through in-services, education, and computerized trainings, and all staff had been trained to her knowledge. The Administrator stated if call lights were not in reach, it could result in residents waiting longer for CNAs to respond. The Administrator stated, it could be something serious that happened and residents would not be able to notify CNAs. Residents Affected - Some A record review of the facility's admission packet dated 12/01/2018 reflected the following: STATEMENT OF RESIDENT RIGHTS You, the resident, do not give up any rights when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights. You have all the rights, benefits, responsibilities, and privileges granted by the constitution and laws of this state and the United States (Rule § 19.402 (a) & (b) Texas Administrative Code and § I 02.003 (a) Human Resources Code). Any violation of these rights is against the law. It is against the law for any nursing facility employee to threaten, coerce, intimidate, or retaliate against you for exercising your rights. You have a right to: 1. ll care necessary for you to have the highest possible level of health A record review of the facility's in-service dated 2/17/2023 reflected staff were trained on the facility's call light policy. A record review of the facility's in-service dated 6/13/2023 reflected staff were trained on customer service instructed not to forget to always put the call light within resident's reach. A record review of the facility's in-service dated 9/06/2023 reflected staff were trained on customer service instructed not to forget to always put the call light within resident's reach. A record review of the facility's in-service dated 10/10/2023 reflected staff were trained on the facility's call light policy. A record review of the facility's policy titled Call Light - Use of dated October 2020 reflected the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675277 If continuation sheet Page 3 of 9 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 10/12/2023 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 0558 Policy Level of Harm - Minimal harm or potential for actual harm It is the policy of this home to ensure residents have a call light within reach that they are physically able to access and that they have been instructed on its use. Residents Affected - Some Procedure 1. All nursing personnel must be aware of call lights at all times. 8. [NAME] providing care to residents, be sure to position the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her how to use the call light. 12. Be sure call lights are placed near the resident, never on the floor or bedside stand. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675277 If continuation sheet Page 4 of 9 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 10/12/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain comfortable sound levels for 7 (Resident #1 and six anonymous residents) of 8 residents reviewed for homelike environment. The facility failed to ensure Resident #22 did not upset other residents in the dining room with his yelling and behaviors during meals. This failure place residents at risk of not having comfortable sound levels. Findings included: A record review of Resident #1's face sheet dated 10/12/2023 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of congestive heart failure, angina (chest pain), Alzheimer's disease (neurodegenerative disease), dysphagia (difficulty swallowing), muscle weakness and osteoporosis (skeletal disorder). A record review of Resident #1's MDS assessment dated [DATE] reflected a BIMS of 12, which indicated moderately impaired cognition. A record review of Resident #1's care plan last revised on 10/10/2023 reflected he had moderately impaired hearing. Interventions included staff were to speak clearly and distinctly. A record review of Resident #22's face sheet dated 10/12/2023 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of malignant neoplasm of brain (brain tumor), dementia (symptoms affecting memory and thinking), cerebral infarction (stroke), dysphagia (difficulty swallowing), pain, and aphasia (difficulty communicating). A record review of Resident #22's MDS assessment dated [DATE] reflected a BIMS of 3, which indicated severely impaired cognition. A record review of Resident #22's care plan last revised on 10/05/2023 reflected he had significant weight loss related to poor intake and spitting out everything he puts in his mouth. Resident #22's care plan reflected he could be sitting in the hall in wheelchair or in dining room and starts yelling and hollering. Interventions included a psych eval, relaxation music and hands on assistance during meals. During a confidential meeting of residents, six out of six residents reported Resident #22 screamed and hollered during meals and it bothered them. Two of seven residents said Resident #22 spat his food out on the table. One of seven residents stated the new administrator was nice and tried a radio, but nothing worked. An observation on 10/10/2023 at 12:50 p.m. revealed residents, including Resident #1, were eating lunch in the dining room. There was country music playing on a boombox in the dining room. Resident #22 was sitting at a table with the SLP and kept yelling hurry, hurry! During an interview on 10/11/2023 at 8:15 a.m., the SLP stated they were trying to figure out why (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675277 If continuation sheet Page 5 of 9 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 10/12/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #22 had had an increase of vocalizations in the last couple of weeks. The SLP stated she did not know whether things were too stimulating for him, and the facility was looking into noise cancelling headphones. The SLP said Resident #22's yelling had been going on for a couple of weeks and him spitting out his food started the last week of September 2023. During an observation and interview on 10/11/2023 at 1:02 p.m., CNA B stated Resident #22's yelling had been going on for months, but she did not know exactly how long. CNA B stated yes the yelling was mostly during mealtimes. Observed Resident #22 sitting in his room with CNA B present and Resident #22 was yelling out Ahhh! CNA B stated someone in therapy would talk with Resident #22 and she thought it was the SLP. CNA B stated she would have to ask the nurse regarding other interventions the facility had tried. CNA B stated the ADON had asked her to go in and observe Resident #22 during lunch that day, but she did not typically work that hallway. During an observation and interview on 10/12/2023 at 8:22 a.m., the SLP was in Resident #22's room encouraging him to eat breakfast. During an observation and interview on 10/12/2023 at 9:47 a.m., Resident #1 was lying in bed. Resident #1 stated Resident #22's yelling had been going on for at least a couple of months. When asked if it was mostly during meals, Resident #1 stated, yeah and it bothers my [family member]. Resident #1 stated Resident #22 yelled and cussed during meals, it bothered him, made him nervous, and said he may get a nervous breakdown. Resident #1 stated we have all complained about it and the supervisor knows. Resident #1 stated nothing would help except for putting Resident #22 in his room. During an interview on 10/12/2023 at 1:55 p.m., the Medical Director stated either himself or one of three other providers visited the facility once monthly. The Medical Director stated, after reviewing notes from Resident #22's last four visits on 9/03/2023, 9/12/2023, 9/27/2023 and 10/12/2023, he did not see any notes about Resident #22's behaviors. The Medical Director stated just because it was not documented, it did not mean the facility did not call them-he stated they did not always put things in the computer. The Medical Director stated the last time he visited Resident #22 was on 7/23/2023 and there was nothing unusual for him. A record review of the facility's in-services from January through October 2023 reflected no in-services on homelike environment. A record review of the facility's resident council minutes titled Resident Council Meeting Form dated 9/12/2023 reflected the following: Nursing: Concern with one resident in dining room yelling constantly and disturbing others eating. Nursing: Concern on one resident [Resident #22] always yelling in dining room for all meals. This document reflected a handwritten note under the nursing concern which read working on concern with the ADON's signature underneath. A record review of the facility's resident council minutes titled RESIDENT COUNCIL MINUTES dated 10/10/2023 reflected Concerns-the yelling in dining room-Nursing. A record review of the facility's grievance titled Grievance/Complaint Report dated 9/12/2023 reflected the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675277 If continuation sheet Page 6 of 9 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 10/12/2023 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 0584 [Resident #1] is upset that a fellow resident (@ times) makes unnecessary noise. It bothers him. Level of Harm - Minimal harm or potential for actual harm Describe the incident as provided by the resident/individual: [Resident #22] keeps too much 'ruckus'. All that hollering bothers me. Residents Affected - Some Describe your findings of the incident: Uncertain of cause, but resident does speak to himself @ times during meals. Recommendations/corrective action taken: Purchase radio for dining room to drown out noise; suggested meals in room; contact resident physician to advise. This grievance reflected it was resolved to the satisfaction of all concerned and marked as resolved on 9/15/2023. During an interview on 10/12/2023 at 4:20 p.m., the ADON stated she was not 100% sure what the facility's policy was on homelike environment when it came to sound levels. The ADON stated they usually monitored every meal and addressed concerns, so residents had a peaceful meal. The ADON stated to address Resident #22's yelling, they had tried earphones for him, he worked with the SLP, they had a radio in the dining room, they tried putting warm clothes on him, lighting, one on one sometimes. The ADON stated herself and the previous DON, whose last day was Monday 10/09/2023, were responsible for monitoring staff to ensure they provided a comfortable environment for residents. The ADON stated most of the time the nurses go around and ask if things are okay during meals. The ADON stated staff helped with interventions she put in place and communicated if they were not working as well. The ADON stated Resident #22's behaviors had been going on for a month or a month and a half, and just Resident #1 had complained about it. The ADON stated if one resident yelled, cursed, and spat during mealtimes, it would not make it a peaceful meal. During an interview on 10/12/2023 at 4:55 p.m., the Administrator stated, we try to accommodate all residents with sound levels. The Administrator stated they noticed Resident #22's yelling so she purchased a radio for mealtimes. The Administrator stated the next intervention was to remove Resident #22 from the dining room but said he was a member of the community, and they did not want to isolate him. The Administrator stated the facility tried earmuffs for Resident #22 to see if he was overstimulated in the dining room. The Administrator stated after trying interventions, she thought they would care plan him to eat in his room. The Administrator stated staff ensured a homelike environment during dining through guidance and education, and through their expectations as a company. The Administrator stated herself and department heads were responsible for monitoring staff to ensure they provided a comfortable environment for residents. The Administrator stated staff were trained on homelike environment through in-services. When asked how other residents may have been affected by one resident who yelled during mealtimes, the Administrator stated, most of them are compassionate and considerate with what's going on with him health-wise. The Administrator stated, then there are some like [Resident #1] who it bothers them, and we have to address it. A record review of the facility's in-services from January 2023 - October 2023 reflected no in-service trainings on homelike environment. A record review of the facility's policy titled Environment dated December 2017 reflected the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675277 If continuation sheet Page 7 of 9 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 10/12/2023 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 0584 following: Level of Harm - Minimal harm or potential for actual harm Policy It is the policy of this home to maintain a homelike environment for its residents. Residents Affected - Some Environment The facility will provide: The facility will maintain comfortable sound levels. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675277 If continuation sheet Page 8 of 9 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 10/12/2023 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 residents' personal effects that could be accommodated in these resident rooms, limit the ability of the residents to move about the room, and decrease residents' quality of life. Findings included: During an interview on 10/12/2023 at 12:16 p.m., the Administrator stated they had requested a waiver for room size in the past, she did not have a physical copy, and the facility would request a waiver again. A record review of the facility's CMS form 2567 dated 9/26/2022 reflected We request a waiver for F912. A record review of the facility's CMS form 672 titled Resident Census and Conditions of Residents dated 10/11/2023 reflected a census of 42. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675277 If continuation sheet Page 9 of 9