Health inspection·December 12, 2024

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete In an interview on 12/12/2024 9:34 AM the DON stated it was her expectation that residents' health information is be keep private to prevent HIPPA violations. The DON stated the nurse should have ensured the computer screen was not visible to passersby. Review of the facility's Policy Resident Rights dated 12/01/2018 reflected A person living in a nursing home or assisted living facility has the same rights as any other resident of Texas and the United States under federal and state laws. These include the right to: Privacy; Confidentiality of records . Event ID: Facility ID: 675277 If continuation sheet Page 2 of 15 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 12/12/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 2 residents (Resident #9) assessments reviewed for PASARR evaluations. The facility failed to refer Resident #9 to the appropriate, State-designated authority when she was diagnosed 09/27/23 with psychotic disorder with delusions due to known physiological condition and psychotic disorder with hallucinations due to know physiological condition. This failure could place residents at risk for not receiving necessary PASARR mental health services, causing a decline in mental health. Findings included: Record review of Resident #9's face sheet dated 12/12/24 revealed an [AGE] year-old female admitted to the facility 09/19/23 with a diagnosis of psychotic disorder with delusions due to known physiological condition, psychotic disorder with hallucinations due to known physiological condition, unspecified mood [affective] disorder, cognitive communication deficit (communication difficulty caused by a cognitive impairment), and generalized anxiety disorder (mental health condition that causes people to experience excessive and uncontrollable worry about everyday events or activities). Record review of Resident #9's annual comprehensive MDS assessment dated [DATE] revealed a BIMS score of 6 indicating severe cognitive impairment. Section I of the MDS assessment also indicated the resident had an active diagnosis of anxiety disorder and psychotic disorder. Record review of Resident #9's care plan revealed the following problems identified: Psychotropic drug use- Resident #9 was at risk for adverse consequences related to receiving antipsychotic and depressant medication for the treatment of anxiety, depression, delusional disorder, and psychotic disorder with interventions. Resident #9 has episodes of disruptive behavior symptoms as evidence by: screaming, shouting, yelling, hollering with interventions. Resident #9 is at risk for social isolation related to anxiety with interventions. Record review of Resident #9's EMR revealed a 1012 form Mental illness/ Dementia Resident Review completed 10/05/23 that revealed it was marked No, the individual does not have a dementia diagnosis or had a dementia diagnosis, but it is not primary Section C of the form Mental Illness Indication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675277 If continuation sheet Page 3 of 15 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 12/12/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was marked Panic or Other Sever Anxiety Disorder, yes, date of onset: 09/19/23 and any other disorder, yes, date of onset: 09/27/23- Delirium due to known physiological condition to which the form instructed If any of the responses are YES, the nursing facility needs to complete a new PL1 and sections D and E for the form, A full PASRR Evaluation will be conducted after the nursing facility submits the new positive PL1. Section D of the form Nursing Facility Action was marked A new positive PL1 was submitted on [date left blank] according to the instructions in section C with DLN [left blank]. Record review of Resident #9's EMR did not reveal a PASRR Evaluation was completed. In an interview on 12/12/24 at 10:09 PM with MDS B she stated the 1012 form to prompt a PASRR evaluation was not submitted. MDS B stated the resident should have a primary diagnosis of Dementia [the record did not show Dementia as a primary diagnosis]. MDS B stated that based on her current listed diagnosis, there should have been another PL1 done so PASRR could have come out to see if she would have qualified for services. MDS B stated that a potential negative outcome of not having completed that form is the resident could be missing out on mental health services and PASRR services if so indicated. In an interview on 12/12/24 at 1:30 PM with the ADM, she stated that the resident who is PASRR positive should be referred to services as a precaution and that a potential negative outcome of not sending the referral is behaviors could increase. The PASRR policy was requested from the DON 12/12/24 at 10:30 AM, she stated there was no PASRR policy and that they just follow PASRR guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675277 If continuation sheet Page 4 of 15 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 12/12/2024 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 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents who are trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization for 1 (Resident #34) of 1 resident reviewed for trauma informed care. Residents Affected - Some The facility failed to ensure that Resident #34 diagnosis of Post-Traumatic Stress Disorder (PTSD) potential triggers were identified, and care planned. The facility failed to ensure that Resident #34 received psychiatric services based on his current diagnosis to evaluate and plan for his care needs. This failure could place residents at increased risk for psychological distress due to re-traumatization. Findings included: Record review of Resident #34's face sheet dated 12/12/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of other schizoaffective disorder (mental health condition that is marked by a mix of schizophrenia symptoms such as hallucinations and delusions, and mood disorder symptoms such as depression, and mania), bipolar disorder (chronic mood disorder that causes intense shifts in mood, energy levels and behavior)-current episode-depressed-severe-with psychotic features, major depressive disorder (mood disorder that causes persistent feeling of sadness and loss of interest)-single episode-unspecified, generalized anxiety disorder, post-traumatic stress disorder-chronic (mental health condition that can develop after someone experiences or witnesses a traumatic event), and assault by unspecified means. Record review of Resident #34's admission MDS assessment dated [DATE] revealed a BIMS score of 15 indicating cognition intact. Section I Active Diagnosis revealed checked for anxiety disorder, depression, bipolar disorder, schizophrenia, and Post Traumatic Stress Disorder. Section N of the MDS revealed the resident was taking an antidepressant. The MDS revealed that Resident #34 did not exhibit any behaviors indicating rejection of care. Record review of Resident #34's care plan last revised 12/05/24 revealed problem identified Resident #34 has diagnosis of PTSD and is at risk for anxiety, hallucinations, irritability, difficulty sleeping, lack of interest in activities, easily startled/ frightened, and loss of memory with interventions administer medications per MD orders, allow extra time for communication as resident may have difficulty expressing thoughts/ needs, encourage resident to express/ talk about feelings as needed, facilitate access to community resources as needed for emotional/ behavioral support, monitor/ document behaviors per facility policy, provide extra time to address resident slowly and calmly to attempt to decrease risk of startling resident. The care plan did not identify any triggers for resident #34 related to the PTSD diagnosis. Additionally, the care plan also identified: Resident #34 has a diagnosis of depression and is at risk of signs and symptoms of distress, symptoms of depression, insomnia, anxiety or sad mood with interventions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675277 If continuation sheet Page 5 of 15 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 12/12/2024 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 0699 - Level of Harm - Minimal harm or potential for actual harm Resident #34 has schizoaffective disorder and is at risk for disorganized thinking, hallucinations, paranoia, insomnia, and delusions with interventions. Residents Affected - Some Resident #34 has a diagnosis of bipolar and is at risk for impaired thought process, manic episodes, major depressive episodes, abnormal elevated moods, suicidal episodes, insomnia, significant weight loss/gain with interventions. Resident #34 has anxiety and is at risk for feelings of fear, worry, irritability, fatigue, restlessness, insomnia, panic attacks, and isolation with interventions. Record review of Resident #34's physician orders revealed an order start date of 09/17/24 for aripiprazole 10mg tablet, 1 tablet oral, at bedtime for diagnosis of other schizoaffective disorder and trazodone tablet, 50mg, 1 tablet, oral at bedtime for diagnosis bipolar disorder, current episode depressed, severe, with psychotic features. Record review of Resident #34's ordered behavior checks with a start date of 10/24/24 for delusions and agitation revealed no behaviors identified. Record review of Resident #34's psychoactive medication therapy consents revealed a consent form dated 09/17/24 for trazodone marked ordered for depression and antidepressant. A second consent form was also reviewed for aripiprazole 10 mg by mouth a day for schizoaffective disorder, bipolar disorder with psychotic features, and mood instability. Resident #34 did not have psych consultations/ assessments for review on 12/12/2024. In an interview on 12/12/24 at 10:22 AM with the DON, she stated Resident #34's PTSD diagnosis was pulled from the last facility he came from and when he was admitted to this facility, he did not exhibit any behaviors that would have caused them to request a psych evaluation. The DON stated that it had been mentioned in the care plan meetings to the resident and his family but stated that despite all his current diagnosis related to mood/behavior disturbances that he is not receiving any psych consultations and they do not know what his PTSD triggers are. When asked if she (the DON) was qualified to evaluate someone as a mental health authority and make that judgement she stated she was not qualified to do that. The DON stated that a potential negative outcome to a resident having multiple diagnosis of mental health disorders that did not have PTSD triggers identified or evaluations by a mental health professional would be he could be missing out on potential resources that could be provided. A policy for trauma informed care was requested from the DON 12/12/24 at 10:30 AM, she stated there was no specific policy for trauma informed care or PTSD. In an interview on 12/12/24 at 1:30 PM with the ADM she stated it was her expectation that PTSD triggers for a resident be identified through verbal education, care plans, and charts. After reviewing Resident 34's diagnosis with the ADM, she stated that she would have reached out to psych services (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675277 If continuation sheet Page 6 of 15 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 12/12/2024 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 0699 and said a potential negative outcome of a resident not being evaluated by psych services would be the potential for them to miss out on needed services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675277 If continuation sheet Page 7 of 15 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 12/12/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medications and biologicals were stored in locked compartments for 1 of 1 treatment carts reviewed for medication storage. The facility failed to ensure the treatment / nurse cart was locked while unattended by LVN A on 12/11/2024. This failure could have resulted in harm due to unauthorized access to medications, biologicals, and needles. Findings included: Observation on 12/11/2024 at 11:25 AM LVN A left the treatment/ nurse cart unlocked and unattended outside of room [ROOM NUMBER] while she performed wound care. In an interview on 12/11/2024 at 11:30 AM LVN A stated she did forget to lock her cart. LVN A stated the cart should have been locked to prevent residents from getting in the cart and having had access to harmful items, like medications and needles. She stated as the nurse/ treatment cart the cart had treatment supplies and medications. In an interview on 12/12/2024 at 9:34 AM the DON stated she expected staff to ensure medication and treatment carts were locked to maintain medication security and prevent residents from having had access to harmful items. Review of the facility's policy medication storage dated 12/2018 reflected It is the policy of this home that medications will be stored appropriately as to be secure from tampering, exposure, or misuse . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675277 If continuation sheet Page 8 of 15 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 12/12/2024 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 - Many 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, and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen and 1 of 1 emergency food storage room reviewed for kitchen and food sanitation. 1. The facility failed to dispose of a bag labeled lunch meat with a manufacture expiration date of 11/23/24. 2. The facility failed to safely store all food items to prevent contamination or spoilage; a bag of pancakes and a bag of waffles were each in a torn bag exposed in the freezer on 12/10/2024. 3. The facility failed to ensure dietary staff followed handwashing procedures on 12/10/2024. 4. The facility failed to ensure 8 gallons of expired water (expired 04/04/24) in emergency storage were cycled out and removed and 3 additional separate damaged gallons of water removed. These failures could place residents at risk for food contamination and foodborne illness. Findings included: During the initial tour of the kitchen on 12/10/24 at 09:03 AM the following were observed: Reach in refrigerator contained a clear zip seal bag that was labeled lunch meat with marker and had a printed manufacturer expiration date of 11/23/24. The bag also had writing on it with marker that said it was opened 12/08/24. In the reach in freezer there was two separate boxes, one contained frozen pancakes and the other frozen waffles. Each box had one bag of each item that had its contents exposed (one bag of waffles, and one bag of pancakes) due to being in a torn bag exposing the contents. During a tour of the separate emergency food storage area on 12/10/24 at 09:25 AM the following were observed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675277 If continuation sheet Page 9 of 15 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 12/12/2024 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 Eight single gallon bottles of water were observed with a printed expiration date of 04/04/24. Level of Harm - Minimal harm or potential for actual harm - Residents Affected - Many Three single gallon bottles of water were observed in a box, all three single-gallon bottles were damaged, caved in, and punctured causing leakage. During a follow up visit to the kitchen for puree observation 12/10/24 at 11:49 AM DC A was observed removing his gloves and placing them in the trash can, touching the trash can by pushing them in, then putting on gloves and going to work on the single serve cakes. Moments later as his gloves appeared to stick to the saran wrap, he removed the gloves and continued to touch the single serve cakes. He was then observed leaving the kitchen area and returning to food preparation multiple times. DC A did not at any point during this time wash his hands after touching the trash can or leaving the kitchen and returning to food preparation. In an interview on 12/10/24 at 09:31 AM with the DM, she stated that it was her expectation that food products are not used past the manufacturer expiration date. She stated the lunch meat that was dated with an open date of 12/08/24 and a printed manufacturer expiration date of 11/23/24 was opened and used past the manufacturer expiration date and should not have been used. The DM stated it was her expectation that dietary staff check daily for expired products and dispose of them and ensure all items opened and placed back in the refrigerator/ freezer are properly sealed in a zip seal bag or airtight container. The DM stated the emergency food storage is checked on a weekly basis and that it is her expectation that expired items are removed. The DM stated the expired water in the emergency supply was overlooked and should have been removed along with the damaged bottles. She stated a potential negative outcome of expired items being served is it could make residents sick. The DM stated that items which are not sealed and stored in the refrigerator/ freezer could have freezer burn, affect the food quality, and lead to spoilage. In an interview on 12/10/24 at 12:03 PM with DC A, he stated he did not think to wash his hands but that a potential negative outcome of not washing his hands after handing contaminated items would be could lead to cross contamination of the food. In an interview on 12/12/24 at 01:30 PM with the ADM, she stated it was her expectation for dietary staff to recognize, keep up with, and prevent expired food items. She stated it was her expectation that items stored in the freezer/ refrigerator were dated and labeled and can be stored in a zip seal bag if it is sealed properly. She stated dietary staff should be washing their hands after touching dirty surfaces. The ADM stated a negative outcome to items not sealed would cause the food to be compromised, the food would not be palatable, and could make residents sick. She stated if dietary staff failed to wash their hands after touching a contaminated item it would result in cross contamination of food. Record review of the Food Storage policy dated 12/01/11 revealed: Policy: The consultant dietician will monitor the storage of foods to ensure that all food served by the facility is of good quality and safe for consumption. All food will be stored according to the stated and federal food codes. Dry storage rooms: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675277 If continuation sheet Page 10 of 15 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 12/12/2024 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 The first in first out rotation method is used. Packages are dated and added items are placed behind existing supplies so that older items are used first. Level of Harm - Minimal harm or potential for actual harm Freezers: Residents Affected - Many Frozen foods are stored in moisture proof wrap or containers that are labeled and dated. Record review of the Employee Sanitation policy dated 10/01/18 revealed: Policy: The nutrition and food service employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes to minimize the risk of infection and food borne illness. Handwashing Employees must wash their hands and exposed portions of their arms at designated hand washing facilities at the following times: Immediately before engaging in food preparation . During food preparation as often as necessary to remove soil and contamination and prevent cross contamination when changing tasks. After engaging in other activities that contaminate the hands. Use of gloves Gloves are not a substitute for thorough and frequent hand washing. When using gloves always wash hands before touching or putting on new gloves. Review of the 2022 U.S. Food and Drug Administration Food Code revealed: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675277 If continuation sheet Page 11 of 15 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 12/12/2024 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 - Many (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: Pf (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Of and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen (2) Is in a container or PACKAGE that does not bear a date or day; P or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17(A). 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. FOOD shall be protected from cross contamination by: (4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the food in packages, covered containers, or wrappings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675277 If continuation sheet Page 12 of 15 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 12/12/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards for one of one resident reviewed for pressure ulcers wound care. (Resident #37). Residents Affected - Few The facility failed to ensure the LVN A followed standard precautions during wound care on 12/11/2024 for Resident #37's stage II right buttock pressure ulcer when she failed to set up a clean field for treatment supplies, used a cleaning technique on the pressure ulcer that did not cross contaminate the pressure ulcer or prevent the pressure ulcer once cleaned from becoming re-contaminated. These failures could place residents at risk for developing wound infections. Findings included: Review of Resident #37's face sheet dated 12/12/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses acute kidney failure (A condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days. Symptoms include legs swelling and fatigue.), Hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms varies from person to person and include unexplained fatigue and headache.), Diabetes Mellitus Type II (A condition results from insufficient production of insulin, causing high blood sugar.) and Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.). Review of Resident #37's admission MDS dated [DATE] reflected he was assessed to have a BIMS score of eight indicating moderate cognitive impairment. Resident #37 was assessed to have physical and verbal behaviors 1 to 3 days during the assessment period. Resident #37 was assessed to require moderate to dependent assist with all ADLs. Resident #37 was assessed to be at risk for pressure ulcers and was assessed to have MASD. Review of Resident #37's comprehensive care plan reflected a problem dated 11/02/2024 Resident #37 had a pressure ulcer related to MASD interventions included Assess the pressure ulcer for stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization, and condition of surrounding skin weekly. Keep clean and dry as possible. Minimize skin exposure to moisture . Further review of Resident #37's comprehensive care plan reflected a problem dated 11/01/204 Resident #37 requires EBP during contact care related to wounds. Interventions included .Staff to provide/utilize appropriate PPE along with standard precautions while providing resident care. (i.e.: ADLs (dressing, grooming, personal hygiene, transfers, linen changes), incontinent care/toileting, wound care . Review of Resident #37's consolidated physician orders reflected an order dated 11/19/2024 Cleanse stage 2 right buttock with normal saline, apply hydrocolloid dressing once a day on Monday and Friday. Observation on 12/11/2024 at 11:27 AM revealed LVN A outside of Resident #37's gathering supplies for his wound care. She placed all the items on a piece of wax paper and brought them into Resident #37's placing them on his overbed table without moving his personal items or cleaning the table. LVN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675277 If continuation sheet Page 13 of 15 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 12/12/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A further brought in an entire box of gloves from her treatment cart and placed them on the table. LVN A then turned Resident #37 to his left side to reveal a stage II pressure ulcer to his right buttock. LVN A using gauze soaked with normal saline cleaned across the pressure ulcer then patted all around the wound and surrounding skin. LVN A then let go of the right buttock allowing the loose skin to fall over the pressure ulcer. LVN A then lifted Resident #37's right buttock again and using a dry gauze patted at the pressure ulcer and without recleaning the pressure ulcer applied the hydrocolloid dressing. In an interview on 12/11/2024 at 11:35 AM LVN A stated she did not clean the overbed table prior to putting her supplies on the table she stated she thought the wax paper was enough. She stated she did not know she could not take the box of gloves out of the room once she brought them in. She stated the gloves would be contaminated once brought into the room and should not be brought back to the cart. She stated she should have cleaned the wound by starting in the center and moving outward. She stated she did not realize she cleaned across the wound. She stated she should have had someone in there to help her because the right buttock did fall back over the wound, and she stated she did not reclean it and should have. LVN A stated by not recleaning the wound after the unclean skin met the wound it became contaminated and could lead to infections. In an interview on 12/12/2024 at 9:34 AM the DON stated it was her expectations for staff to perform wound care in an aseptic (free from contamination by harmful bacteria, viruses, or other microorganisms) in a manner that does not contaminate the wound. She stated once items are brought into the room they are contaminated and should not be put back on the carts. Review of the facility's policy infection control- standard precautions dated 12/2018 reflected It is the policy of this home that staff members will use standard precautions when providing resident care or when there is the potential of coming into contact with contaminated items. The facility's policy did not address infection control in wound care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675277 If continuation sheet Page 14 of 15 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 12/12/2024 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 forty-nine resident rooms were less than the required space of eighty 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 12/12/2024 at 9:00 AM, 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 thirty-eight. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675277 If continuation sheet Page 15 of 15