Health inspection·January 24, 2023

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Box/Safe Verification Record. Cart C/D, with missing signatures on the following dates: 1/3/23, 1/6/23, and 1/12/23. Record review of the facility's policy titled, Narcotic Controlled Medication, no date, revealed, .At the change of shift the on coming and out going staff persons jointly count all controlled medications, including discounted or expired medications awaiting destruction . During an interview on 1/19/23 at 01:15 pm with Director of Nursing (DON), the Director of Nursing acknowledged the above findings and stated she has acknowledged the above findings and stated that it can be a detriment to the 65 residents and met with LVN A for counseling in regard to the unsecured controlled narcotics. During an interview on 1/19/23 at 01:15 pm with the Administrator, the above findings were discussed. The Administrator acknowledged the above findings. The Administrator acknowledged that the findings place the 65 residents at risk and met with LVN A for counseling in regard to the unsecured controlled narcotics. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675369 If continuation sheet Page 2 of 10 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 675369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grandview Nursing and Rehabilitation Center 301 W Criner St Grandview, TX 76050 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for one of one kitchen. Residents Affected - Many The facility failed to ensure food in the walk-in freezer, walk-in refrigerator and dry storage room was properly stored, dated, and labeled. The deficient practice placed residents who were served from the kitchen at risk for health complications and foodborne illnesses. Findings included: Observation of the dry storage area in the kitchen on 01/18/2023 at 9:30 am, revealed various items; bag of chips open and not properly sealed, labeled or dated, package of what appeared to be corn tortillas opened but not labeled or dated, plastic storage containers with what appears to be dry cereal not labeled or dated, an open bag of pasta not sealed nor labeled or dated. Further observations in the dry storage area revealed boxes of supplies (appeared to be disposable cups and plates) that were stored on the floor in the dry storage area. Observation of the walk-in freezer in the kitchen on 01/18/2023 at 10:05 am, revealed multiple boxes of frozen food items stored directly on the floor of the freezer obstructing the entrance. Zip lock bag (open and not sealed) of what appears to be frozen biscuits. A 10-gallon bucket of ice cream opened but not labeled or dated. A tray of what appears to be disposable plastic cups of ice cream not covered, sealed, labeled, or dated. Zip lock bag of what appears to be frozen dinner rolls that are not labeled or dated. A zip lock bag of what appeared to be frozen chicken fried steaks that were not labeled or dated. Observation of the walk-in refrigerator in the kitchen on 01/18/2023 at10:30 am, revealed a brown bag and a Styrofoam bowl of what appears to be personal food items from a restaurant that is being stored in the resident refrigerator. A tray of beverages (Juice and milk) that were covered with plastic but not labeled or dated. An opened bottle of what appears to be prune juice that is not labeled or dated. Observation and Interview with the Dining Services Supervisor on 01/18/2023 at approximately 10:45 am, revealed that items stored in the walk-in freezer should not be stored of the floor, but they just received their shipment and have not had the time to unload. The DSS was shown all items that were open but not labeled or dated, and the DSS stated They should all be sealed, dated for discard date of expiration and labeled. The DSS was shown boxes on the floor in the dry storage area and stated they do have a storage area for those items and will place those when she gets the chance to move them but understands that these items do not store on the floor. The DSS stated that all the food in the kitchen area (dry, refrigerator and freezer) was available for resident consumption. The DSS was shown multiple bags of items in the dry storage area that were not sealed properly or labeled and dated. The DSS stated that they would make sure all items were labeled and dated. The DSS stated I recently returned to the kitchen and have been out the facility due to medical reasons, but we do have a Dietary Services Manager and we both are responsible for the kitchen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675369 If continuation sheet Page 3 of 10 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 675369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grandview Nursing and Rehabilitation Center 301 W Criner St Grandview, TX 76050 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 Observation and Interview with the Dietary Services Manager on 01/18/2023 at approximately 12:10PM revealed that they recently received a shipment of frozen items but understand that those items should not be stored on the floor of the freezer. The DSM was shown the items in the dry storage area that were not labeled or dated. The DSM stated that the items should be sealed, labeled, and dated but she would walk through and make sure these items are discarded and in-service staff about making sure to label and date those items once they are opened. Observation and Interview with the ADMIN on 01/20/2023 at approximately 12:07PM, revealed the ADMIN was shown the items that were still not properly sealed, dated or labeled. The ADMIN stated food should be stored and labeled properly and it is the dietary manger's responsibility to ensure this is done. The Admin stated, If food is not sealed properly, dated or labeled that there is a risk of food borne illnesses for the residents of the facility. The ADMIN was observed throwing away all items not properly sealed, labeled or dated while walking through the dry storage area. The ADMIN was shown items in the walk-in refrigerator that were not properly labeled or dated. The ADMIN was also shown what appeared to be personal drink bottles in the facility refrigerator. The ADMIN stated, That these items are not to be stored with resident food for consumption. Observation of the ADMIN which informed dietary staff that they should not store their personal items in this refrigerator, and they have a break room for personal items. The ADMIN was also shown the walk-in freezer where boxes were still on the floor blocking the entrance and being stored on the floor. Review of facility 672 form Resident census and conditions of residents dated 01/18/2023, revealed no residents were on tube feedings. Review of facility policy Date Marking for Food Safety dated: effective 2021, revealed The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for food safety. Policy Explanation and Compliance Guidelines for Staffing: 1. Refrigerated, ready-to-eat, time/temperature control for safety food (i.e. perishable food) shall be held at a temperature of 41 °F or less for a maximum of 7 days. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded. The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest. The date of opening or preparation counts as day 1. (For example, food prepared on Tuesday shall be discarded on or by Friday.) The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. The Dietary Manager, or designee, shall spot check refrigerators weekly for compliance, and document accordingly. Corrective action shall be taken as needed. Note: prepared foods that are delivered to the nursing units shall be discarded within two hours, if not consumed. These items shall not be refrigerated as the time/temperature controls cannot be verified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675369 If continuation sheet Page 4 of 10 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 675369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grandview Nursing and Rehabilitation Center 301 W Criner St Grandview, TX 76050 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 Based on observations, interviews, and record reviews, the facility failed to establish and maintain an IPCP designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections for 33 of 65 residents (Resident #1, #2, #5, #9, #10, #12, #15, #17, #24, #25, #29, #30, #31, #33, #37, #39, #40, #41, #43, #44, #45, #49, #52, #53, #54, #55, #58, #59, #63, #66, #67, #221, and #222) reviewed for infection control. Residents Affected - Some The facility failed to determine how and when to use isolation precautions for 31 of 65 residents (Resident #1, #2, #5, #9, #10, #12, #15, #17, #24, #25, #29, #30, #31, #33, #37, #39, #40, #41, #43, #44, #45, #49, #53, #54, #55, #58, #59, #63, #67, #221, and #222). 13 of 31 residents (Residents #1, #5, #9, #10, #30, #31, #33, #39, #43, #45, #49, #58, and #221) who were negative for COVID-19 were housed in rooms next to and across from 18 of 31 residents (Residents #2, #12, #15, #17, #24, #25, #29, #37, #40, #41, #44, #53, #54, #55, #59, #63, #67, and #222) who were positive for COVID-19 and on isolation precautions. While there were signs on the room doors of residents who were positive for COVID-19 indicating they were on isolation precautions, the doors were left open for all 31 residents. The facility failed to monitor and provide an accurate roster for all 65 residents. The facility failed to annually review and update, as necessary, its IPCP. These deficient practices could place residents at risk for exposure to COVID-19, which could result in spread of infectious disease, and possibly serious illness. Findings include: Record review of intake #399193 dated 01/08/23 revealed the DON reported residents #39, #49, and #66 tested positive for COVID-19. Intake #399193 was the most recent report related to infection control. Record review of the daily census dated 01/18/23 revealed residents #2, #24, #25, #52, #54, #55 and #67 tested positive for COVID-19 and were on isolation precautions. In an interview on 01/18/23 at 9:46 am, the Admin stated she and the DON notified the families of residents who were exposed to, showed symptoms and/or tested positive for COVID-19. In an interview on 01/18/23 at 10:20 AM, the DON stated there were 17 residents who tested positive for COVID-19. The DON did not identify the 17 residents who tested positive for COVID-19. Record review of the facility's COVID-19 positive list dated 01/19/23 revealed residents #2, #12, #15, #17, #24, #25, #29, #37, #40, #41, #44, #52, #53, #54, #55, #59, #63, #67, and #222 tested positive for COVID-19. Residents #52, #53 and #67 tested positive for COVID-19 on 01/09/23, residents #29, #41 and #59 tested positive for COVID-19 on 01/10/23, residents #40, #44, #59 and #63 tested positive for COVID-19 on 01/12/23, residents #2, #15 and #54 tested positive for COVID-19 on 01/13/23, resident #12 tested positive for COVID-19 on 01/14/23, residents #17 and #222 tested positive for COVID-19 on 01/15/23, and residents #24, #37 and #55 tested positive for COVID-19 on 01/16/23. Record review of the COVID-19 prevention and response policy dated 03/10/2020 revealed when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675369 If continuation sheet Page 5 of 10 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 675369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grandview Nursing and Rehabilitation Center 301 W Criner St Grandview, TX 76050 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 - Some COVID-19 was suspected, the facility must notify the resident's physician and family, DON, IP and local health department. In an interview on 01/19/23 at 9:14 AM, the MD stated the facility notified him of each resident who tested positive for COVID-19 via email. The MD stated he did not keep a log of residents who tested positive for COVID-19. The MD stated he did not realize there were 19 residents who tested positive for COVID-19. The MD stated he thought there were six residents who tested positive for COVID-19 until the facility contacted and updated him at night on 01/18/23. In an interview on 01/20/23 at 5:00 PM, the DON stated her expectation was that residents who tested positive for COVID-19 were immediately reported to the appropriate parties. The DON stated she reported COVID-19 positive cases every Monday and Thursday. The DON stated she forgot to report the new COVID-19 positive cases to the appropriate parties. During an observation on 01/18/23 at 9:20 AM, there were no signs on the front door related to COVID-19. Record review of the interim COVID-19 visitation policy dated 03/13/20 revealed the facility must communicate the visitation policy through multiple channels, instructing visitors to defer visitation until further notice. Channels of communication examples included signage, calls, letters, social media posts, emails, and recorded messages for receiving calls. Record review of the COVID-19 prevention and response policy dated 03/10/2020 revealed the facility must post signs at the entrance instructing visitors not to visit if they have symptoms of respiratory infection. In an interview on 01/20/23 at 5:00 PM, the DON stated her expectation was that there were signs on the front door indicating residents who were positive for COVID-19 were in the building. The DON stated she and the Admin were responsible for ensuring there were signs at the front door indicating residents who were positive for COVID-19 were in the building. The DON stated she did not know there were not signs on the front door indicating residents who were positive for COVID-19 were in the building. The DON stated having no signs at the front entrance indicating residents who were positive for COVID-19 were in the building could place visitors at risk of exposure to COVID-19. Record review of the interim COVID-19 visitation policy dated 03/13/20 revealed visitors, health care workers, and surveyors must be screened for fever or respiratory symptoms and illness prior to entry. Record review of the COVID-19 prevention and response policy dated 03/10/2020 revealed visitors of persons with known or suspected COVID-19 must be screened for symptoms of acute respiratory illness. In an interview on 01/18/23 at 9:00 AM, the DON stated residents who were positive for COVID-19 were housed in rooms on hall B. In an interview on 01/18/23 at 10:42 AM, the DON stated residents who were positive for COVID-19 and could not be housed in rooms on hall B were housed in rooms on hall A. During an observation on 01/18/23 at 11:15 AM, there were no signs indicating there were residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675369 If continuation sheet Page 6 of 10 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 675369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grandview Nursing and Rehabilitation Center 301 W Criner St Grandview, TX 76050 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 - Some who tested positive for COVID-19 housed in rooms on halls A and B prior to entry. The corridors for halls A and B were also open. Record review of the daily census dated 01/18/23 revealed residents #12, #15, #17, #37, #40, #41, #44, and #222 tested positive for COVID-19, were on isolation precautions and housed in rooms on hall A. Residents #2, #24, #25, #53, #54, #55 and #67 tested positive for COVID-19, were on isolation precautions and housed in rooms on hall B. In an interview on 01/18/23 at 12:00 PM, CNA A stated the Admin and DON told staff that the facility did not have to post signs indicating residents who tested positive for COVID-19 were housed in rooms on halls A and B prior to entry. In an interview on 01/18/23 at 12:24 PM, LVN A stated the Admin told staff that the facility did not have to post signs post signs indicating residents who tested positive for COVID-19 were housed in rooms on halls A and B prior to entry. In an interview on 01/19/23 at 9:14 AM, the MD stated all residents who were positive for COVID-19 should be housed in rooms on one hallway. The MD also stated there should be a sign posted prior to entry on the hallway indicating there were residents who tested positive for COVID-19 housed in rooms on the hallway. In an interview on 01/20/23 at 5:00 PM, the DON stated her expectation was that there were signs indicating there were residents who tested positive for COVID-19 housed in rooms on halls A and B prior to entry. The DON stated not having signs indicating there were residents who tested positive for COVID-19 housed in rooms on halls A and B prior to entry placed residents and visitors at risk for exposure to COVID-19. During an observation on 01/18/23 at 11:13 AM, residents #2, #12, #15, #17, #24, #25, #29, #37, #40, #41, #44, #53, #54, #55, #59, #63, #67, and #222 were positive for COVID-19 and on isolation precautions. Residents #2, #12, #15, #17, #24, #25, #29, #37, #40, #41, #44, #53, #54, #55, #59, #63, #67, and #222 had plastic storage organizer drawers full of PPE supplies outside each of their rooms and signs posted on each of their doors indicating they were on isolation precautions. Residents #1, #5, #9, #10, #30, #31, #33, #39, #43, #45, #49, #58, and #221 were negative for COVID-19 and not on isolation precautions. Residents #1, #5, #9, #10, #30, #31, #33, #39, #43, #45, #49, #58, and #221 did not have signs posted on each of their doors and plastic storage organizer drawers full of PPE supplies outside each of their rooms. In an interview on 01/18/23 at 12:00 PM, CNA A stated there were no designated CNAs for residents who were positive for COVID-19. CNA A stated CNAs provided care and services to residents on all hallways. CNA A stated residents who tested positive for COVID-19 were moved and placed in rooms on hall B. The CNA A stated residents who tested positive for COVID-19 were cohorted with other residents who tested positive for COVID-19. CNA A stated residents who tested positive for COVID-19 were also placed in rooms on hall A when there were no more rooms available on hall B. CNA A stated residents who had signs labeled, Check at nursing station prior to entering, and yellow barrels inside their rooms were determined to be positive for COVID-19 and on isolation precautions. CNA A stated residents had their room doors left open because some of them were at risk for falling. CNA A stated there were three residents on hall B who were negative for COVID-19, placed in rooms next door to residents who were positive for COVID-19 and on isolation precautions, and had their room doors left open. CNA A did not identify who were the three residents who were negative for COVID-19 on hall B. CNA A (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675369 If continuation sheet Page 7 of 10 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 675369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grandview Nursing and Rehabilitation Center 301 W Criner St Grandview, TX 76050 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 - Some stated whenever staff were in the hallways, they monitored residents to ensure residents do not wander into other residents' rooms. CNA A stated staff have brought the concern to the DON and Admin's attention. CNA A stated the DON and Admin were aware of the potentiality for exposure and further spread of COVID-19 in the facility. CNA A stated the Admin and DON told staff that residents who were positive for COVID-19 did not have to keep their doors closed even if they were on isolation precautions. CNA A stated there was no intervention put in place to prevent residents from wandering into other residents' rooms. CNA A stated there was a growth of residents who were exposed and tested positive for COVID-19 at the facility. CNA A stated having residents' room doors left open placed residents at risk for wandering into another resident's room who may be positive for COVID-19 and on isolation precautions and becoming exposed to COVID-19. In an interview on 01/18/23 at 12:24 PM, LVN A stated each LVN was assigned two hallways. LVN A stated residents who had signs labeled, Check at nursing station prior to entering, and plastic storage organizer drawers full of PPE supplies outside their rooms were determined to be positive for COVID-19 and on isolation precautions. LVN A stated residents who tested positive for COVID-19 were placed on isolation precautions for 14 days and until they tested negative for COVID-19. LVN A stated there were residents who were negative for COVID-19 and placed in rooms next door to residents who were positive for COVID-19 and on isolation precautions on halls A and B. LVN A did not identify who the residents were who were negative for COVID-19. LVN A stated residents' doors remained open so staff can monitor residents who were at risk for falls. LVN A stated residents who were negative for COVID-19 were required to wear their masks before exiting their rooms. LVN A stated residents who were positive for COVID-19 and on isolation precautions were redirected back to their rooms by staff if they wandered out of their rooms. LVN A stated the Admin told staff that residents who were positive for COVID-19 were not required to close their doors even if they were on isolation precautions. LVN A stated having residents' room doors left open placed residents at risk for wandering into another resident's room who may be positive for COVID-19 and on isolation precautions and becoming exposed to COVID-19. Record review of the COVID-19 prevention and response policy dated 03/10/20 revealed the facility must restrict residents with a fever or acute respiratory symptoms to their room. The policy also revealed when COVID-19 was suspected, the facility must place the resident in a private room (containing a private bathroom) with the door closed. In an interview on 01/19/23 at 9:10 AM, resident #37 stated she was positive for COVID-19 and on isolation precautions. Resident #37 stated she was concerned with the potentiality of other residents who were negative for COVID-19 wandering into her room and becoming exposed to COVID-19. In an interview on 01/19/23 at 9:22 AM, resident #54 stated she was positive for COVID-19 and on isolation precautions. Resident #54 stated she was concerned with the potentiality of other residents who were negative for COVID-19 wandering into her room and becoming exposed to COVID-19. In an interview on 01/19/23 at 9:14 AM, the MD stated, residents' doors should be closed if they are positive for COVID-19. The MD stated, residents who were negative for COVID-19 should be kept away from residents who were positive for COVID-19. In an interview on 1/19/23 at 9:45 AM, resident #40 stated she was positive for COVID-19 and on isolation precautions. Resident #40 stated she was concerned with the potentiality of other residents who were negative for COVID-19 wandering into her room and becoming exposed to COVID-19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675369 If continuation sheet Page 8 of 10 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 675369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grandview Nursing and Rehabilitation Center 301 W Criner St Grandview, TX 76050 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 - Some In an interview on 01/20/23 at 5:00 PM, the DON stated she was aware that there were residents who were negative for COVID-19 placed in rooms next door and across from residents who were positive for COVID-19 and on isolation precautions on halls A and B. The DON stated she was not aware that residents on halls A and B had their room doors left open. The DON stated she was responsible for training staff on isolation precaution procedures. The DON stated having residents' room doors left open placed residents at risk for wandering into another resident's room who may be positive for COVID-19 and on isolation precautions and becoming exposed to COVID-19. Record review of the daily census dated 01/18/23 revealed residents #12, #15, #17, #37, #40, #41, #44 and #222 were positive for COVID-19 and housed on hall A. Residents #10, #31, #39, #52, #53, #66 and #221 were housed on hall B. Residents #10, #31, #39, #66, and #221 were negative for COVID-19 and residents #52 and #53 were positive for COVID-19. Record review of the daily census dated 01/19/23 and 01/20/23 revealed residents #12, #15, #17, #37, #40, #41, #44 and #222 were positive for COVID-19 and not housed on hall A. Residents #10, #31, #39, #66, and #221 were negative for COVID-19 and residents #52 and #53 were positive for COVID-19 and not housed on hall B. In an interview on 01/18/23 at 3:28 PM, the DON stated she was the IP. Record review of the COVID-19 prevention and response policy dated 03/10/20 revealed the IP must identify and monitor residents who may have been exposed if COVID-19 was confirmed. In an interview on 01/20/23 at 5:00 PM, the DON stated she was responsible for identifying and monitoring residents who were exposed to, showed symptoms for, and/or tested positive for COVID-19 and providing an accurate roster for all 65 residents at the facility. The DON stated she was not aware of the inaccuracies in the facility roster. The DON stated not identifying and monitoring residents who were exposed to, showed symptoms for, and/or tested positive for COVID-19 and accurate roster for all 65 residents at the facility placed the residents and staff at risk for exposure to COVID-19, which could result in a growth of positive COVID-19 cases and staffing shortage at the facility. Record review of the COVID-19 prevention and response policy dated 03/10/20 revealed the policy was implemented, reviewed, and revised by the DON on 03/10/20. Record review of the interim COVID-19 visitation policy dated 03/10/20 revealed the policy was implemented on 03/10/20, reviewed on 03/13/20, and revised by the DON. In an interview on 01/20/23 at 5:00 PM, the DON stated the IPCP was reviewed two or three times a week. The DON stated she was responsible for reviewing and revising the IPCP annually and as necessary. The DON stated she was not reviewing and revising the infection control policies and procedures. The DON stated she was not reviewing the infection control policies and procedures with staff. The DON stated she was responsible for providing staff with training related to infection control and reviewing the infection control policies and procedures with staff. The DON stated not reviewing and revising the IPCP placed residents, staff, and visitors at risk for exposure to COVID-19, which could result in a growth of positive COVID-19 cases and staffing shortage at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675369 If continuation sheet Page 9 of 10 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 675369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grandview Nursing and Rehabilitation Center 301 W Criner St Grandview, TX 76050 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 0882 Level of Harm - Minimal harm or potential for actual harm Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interviews, and record reviews, the facility failed to ensure a person designated as the infection preventionist worked at least part-time at the facility. Residents Affected - Many The facility did not have an infection preventionist in place who worked at least part-time at the facility. The DON was the infection preventionist and did not work at least part-time in the position at the facility. This deficient practice could place residents at risk of cross contamination and infection. Findings included: In an interview on 01/18/23 at 9:46am, the Admin stated the DON was the IP for the facility. In an interview on 01/18/23 at 3:28pm, the DON stated she was the IP for the facility. The DON stated she was the IP since 01/16/23. In an interview on 01/19/23 at 10:00am, the DON stated she was the IP since CMS made it a requirement for facilities to have an IP. In an interview on 01/20/23 at 2:34pm, the DON stated she worked as the IP for 10 hours a week. The DON stated the facility hired a new IP on 01/16/23 because she was not able to dedicate at least part-time to the position. Record review of the new IP's personnel file revealed she was hired on 01/16/23 and started working at the facility on 01/17/23. Record review of the DON's timesheet dated 01/20/23 revealed the DON worked an average of 40.5 hours per week as the DON. The DON's timesheet did not indicate how many hours she worked as the IP. Record review of the COVID-19 prevention and response policy dated 03/10/20 revealed there was no mention of the amount of time required to be dedicated by the IP to monitor the facility's IPCP. In an interview on 01/20/23 at 5:00pm, the DON stated she was aware that the IP was required to work at least part-time at the facility. The DON stated the IP not working at least part-time at the facility could place the residents, staff, and visitors at risk for exposure to COVID-19, which could result in a growth of positive COVID-19 cases and staffing shortage at the facility. The DON stated she would provide a policy, procedure, and job description on infection preventionist. The facility did not provide a policy, procedure, and job description on infection preventionist. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675369 If continuation sheet Page 10 of 10