Inspection·May 22, 2023

F 0700 Level of Harm - Immediate jeopardy to resident health or safety Focus: Resident #1's initial care plan dated 09/23/2022 revealed Resident #1 was at risk for falls related to weakness and debility. Goal: Restraints used to prevent falls will be minimized/eliminated by target date 9/21/2022 Interventions: Anticipate and meet the resident's needs Residents Affected - Few Be sure resident's call light is in reach. The resident requires prompt response to all requests. Focus: The resident uses side rails for repositioning Goal: The resident will remain free of complications related to side rails. Intervention: Discuss with the residents/family the risk and benefits when using side rails should be applied. Record review of Resident #1's initial assessment dated [DATE] or any other assessment until 05/18/2023 revealed there were no consents, no risk assessment or physician's orders for bed side rails. Record review of facility provided list revealed 12 residents who had bed rails none included consents, risk assessment or physician orders. Observation on 05/18/23 at 11:30 a.m. of each resident's bed revealed bed side rails were in place attached to the beds. Interview with the DON on 5/19/23 at 11:10 AM revealed if the facility had the physician's orders, consent, and risk assessments, they would be in the clinical record. She specified this was the responsibility of the DON Record review of the facility's self-report investigation dated 05/18/23 revealed the following: Resident #1 was noted to be against the left side rail with his lower body off the bed on 12/28/2022. No injury was noted. A small indention on his chest was indicated. No adverse reaction was noted. Actions and notifications reflected the resident was assessed for injury. The physician and family were notified. The family was educated prior to incident and post incident of side rail safety. Review of a 43 minute and 41-second-long video dated 12/28/22 beginning at time stamp 5:36 revealed: The door to Resident #1's room could not be view if his door was open or closed. -1-3 minutes - Resident #1 was lying on his back in bed, with half side rails up on each side of the bed. Resident #1 was holding the left side rail with his left hand. There was a trapeze bar hooked up to the bar above the bed, out of reach. Resident #1 was appeared restless and was fidgeting and adjusting the covers. He turned himself from his back to his left side, called out for help, then rolled back to his back - 4:00 - Video Timeline beginning: Resident #1 was rattling/shaking the side rail while yelling help - 4:47- Resident #1 turned onto his left side, moved his right leg across his body and off the bed. Resident #1's lower right side of his body rolled toward the left side off the bed onto knees. His upper left side of his body from the waist up remained between the side rail and mattress, with his right arm holding the top of the side rail. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675554 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Care Center of Nocona 306 Carolyn Rd Nocona, TX 76255 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 0700 Level of Harm - Immediate jeopardy to resident health or safety - 5:01- Resident #1 raised his head and looked around. His left arm was between the side rail and mattress. He attempted to push himself up with his leg and right arm. - 5:30 - 7:00- Resident #1 yelled, Help six times and rested his head on the mattress. His left arm remained between the mattress and the side rail. Resident #1 yelled, I can't., Help. an additional four times. Resident #1 yelled, Help; laying on the floor. twice. Residents Affected - Few - 7:40- Resident #1 was getting lower in the side rail and his chin was below the top of the side rail. Resident #1 used his right arm to try to raise himself up; his left arm remained between the side rail and mattress. - 7:53- Resident #1 yelled, Come help please, please come help. four times. - 9:00- Resident #1 pulled his pillow from the head of his bed and rested his head on it, yelling, Help - 12:41- Resident 31 yelled, Help, I'm in distress, and was making grunting noises, and said, Please come see. - 13:09 - Resident #1 said, I'm hurtin' bad; was grunting, and said, Please come see .my back's killing me .I can't move .Ohhh .Come on. - 14:01-15:30- Resident #1 continued to yell Help, and mad grunting noises. - 16:00-19:00- Resident #1 yelled, Ya gotta come .help .oh the pain .help me Resident #1 was lower to the ground, with the side rail pressing against his chest, his left arm remained between the side rail and mattress, and the top of the side rail was up to his chin. - 20:54- Resident #1 yelled repeatedly, Help me I'm gonna die here. - 21:28-The top of the rail was at Resident #1's ear level. Resident #1 yelled, Help me I'm gonna die., while using his right hand to pull the side rail away from his neck. - 28:00- Resident #1 yelled, Ah, ah .ah repeatedly and pulling the side rail away from his neck while grunting and groaning. - 34:30- Resident #1 said, Help I'm gonna die here, please help. - 38:41- Staff could be heard saying, We are right here .oh god go get the nurse Record review of the incident report revealed LVN A documented on 12/28/2022 the following: Skilled Nurse was called to Resident #1 room and noted both legs out of the bed and on the floor mat. Upper body in bed with right side of chest pressed against the bed rail (left side of bed), resident states I rolled out of bed. Immediate Action Taken: Assessment done range of motion performed resident helped off of the floor PCP, Administrator, DON, Hospice Nurse, and POA notified. Type of Injury: Location-chest (no measurements of wound/bruise) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675554 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Care Center of Nocona 306 Carolyn Rd Nocona, TX 76255 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 0700 Predisposed situation factor: Bedside rail up. Level of Harm - Immediate jeopardy to resident health or safety During an interview on 05/18/2023 at 12:30 PM LVN A said she was Residents Affected - Few there (started dayshift on 12/28/22) when Resident #1 was found caught between the bed rail and the mattress. LVN A said Resident #1 was trapped, and she heard him crying out for help. She said he had a large (unmeasured an opinion of the size) indention in his chest and he was complaining of pain. In regard to the incident report LVN A said initially there was not a bruise but an intention to his chest a little later. LVN A said she lifted his arm out from between the mattress and the railing and Resident #1 said it was painful. LVN A said the railings were up on both sides of the bed. LVN A said she went out into the hall and got CNA B to help, and they both lifted him up onto the bed. LVN A said the incident was communicated to the DON and she was told to call the physician after her assessment. LVN A said that all the beds in the facility have always had bed rails, all different types and sizes, but she said Resident #1 always went around the rails and scooted himself off the bed onto the floor mat, and that she never saw him grab on to the bed rails for assistance, she said she never mentioned this event (scooting himself off the bed) to anyone. LVN A said that she understood there was a probability for entrapment and injury with the use of any size bed rail, and there was the need for a consent due to the risks, and that an order had to be given by a doctor before the bedrails were applied to any resident's bed. Attempts to interview the PCP on 05/18/2023 at 1:00 PM and 05/19/2023 at 8:30 AM were unsuccessful due to no one answering the telephone and not returning calls after leaving a message. During an Interview with CNA B on 05/18/2023 at 3:15 PM revealed she did not remember the incident it was long time (December 2022) and does not remember what happened. She said she was at the facility when the incident happened but does not remember what happened. CNA B was asked what she would do if a resident was trapped in a bed rail and she said she would call out for help from her partner and never leave the room and get the nurse or someone. During a subsequent interview with CNA B on 05/18/2023 at 4:30 PM revealed on 12/28/22 she heard Resident #1 was yelling out and went to Resident #1's room and found him on the floor and holding the bed rail. She said she stayed with him and yelled for LVN A to help her get Resident #1 off the floor. LVN A arrived and helped CNA B get Resident #1 off the bed rail. She said he was holding the bed rail. During an interview with LVN C on 05/18/2023 at 4:45 PM revealed she was working on 12/28/2023 and unable to recall the incident. She said she was working that shift, but LVN A started the shift and was notified that Resident #1 was on the floor. She said she just heard that Resident #1 was caught in the bed rail. She said she did not know if Resident #1 had a physician's orders or if he had a bed rail assessment. During an observation on 05/18/2023 at 11:45 AM revealed a bed rail similar to Resident #1's bed had large bolts holding the rails in place, this potentially could have been pressing against Resident #1's chest. During an interview on 05/19/2023 at 10:45 AM with the DON and Administrator revealed the video shown of Resident #1 being caught in the bed rail, the DON said it should not have taken staff 45 (actually 31 minutes per video) to assist the resident who (DON and Administer said it looked like he was holding the rail and not caught in the bed rail just holding it). The Administrator said he was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675554 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Care Center of Nocona 306 Carolyn Rd Nocona, TX 76255 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 0700 holding the rail and did not think it needed to be reported to the state. Level of Harm - Immediate jeopardy to resident health or safety On 05/19/2023 at 5:10 PM an Immediate Jeopardy was identified, and the Administrator was informed. The IJ Template was provided at this time. Residents Affected - Few During an interview with DON on 05/20/2023 at 11:00 AM the DON said she was unable to locate documentation for physician's orders, a bed rail assessment, consent to use the bed rails, or alternatives to use of the bed rails. Physician orders, bed rail assessment, consents and alternatives for bed rails was created and signed by the family and representatives as part of the Plan of Removal was provided at this time. (05/20/2023 at 11:00 AM) During an interview and observation on 05/20/23 from 4:00 PM until 5:00 PM) revealed the Certified Occupation Therapist assessed 12 residents on 05/20/2023 beginning at 4:00 PM using bed rails and assessed each resident for bed rail use. One resident's bed rail was discontinued and recommendation for overhead bed trapeze be included. During an interview on 05/20/23 at 11:00 AM the Maintenance Director said Resident #1's bed was supplied by the hospice service and his bed rails were already placed on the bed. He said he was unaware of any alerts or recalls by the manufacturer regarding bed rails. Review of the website: https://www.fda.gov/media/88765/download on 05/24/2023 at 4:00 PM revealed the recommendations for bed rail assessment. Resident Assessment After a facility has attempted alternatives to bed rails and determined that these alternatives do not meet the resident's needs, the facility must assess the resident for the risks of entrapment and possible benefits of bed rails. In determining whether to use bed rails to meet the needs of a resident, the following components of the resident assessment should be considered including, but not limited to: o medical diagnosis, conditions, symptoms, and/or behavioral symptoms. o Size and weight o Sleep habits o Medication(s) o Acute medical or surgical interventions o Underlying medical conditions o Existence of delirium o Ability to toilet self safely o Cognition (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675554 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Care Center of Nocona 306 Carolyn Rd Nocona, TX 76255 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 0700 o Communication Level of Harm - Immediate jeopardy to resident health or safety o Mobility (in and out of bed) Residents Affected - Few The following Plan of Removal was accepted on 5/20/23 at 11:45 AM. The Plan or Removal reflected the following: o Risk of falling. 1. Resident #1 was assisted by staff back to bed on 12/28/2022.Resident #1 was assessed by the licensed nurse on 12/28/22with a small red indention noted to his upper middle chest, no other marks or injuries noted. Resident #1 was discharged from the facility on 2/26/23. 2. Residents have been reassessed/re-evaluated for use of bed rails to meet resident needs by the DON and designee on 5/19/2023. Those residents that require bed rails as an enabler have received verbal orders from the Medical Director on 5/19/2023. Residents/Responsible Party have been notified of the use of bed rails as an enabler for consent by the DON or designee on 5/19/2023. The DON or designee will review care plans for residents with side rails on or before 5/20/2023 to ensure care plans reflect current interventions and needs related to side rail use. The Maintenance or designee removed bed rails on 05/20/2023 from residents' beds that do not require bed rails as an enabler device and verified by surveyor. Therapy will screen residents for bed rail use on or before 5/20/2023 on the recommendation of the Certified Occupation Therapy Assistant on 05/20/23 on 4:30 PM two bed rails were removed and/or modified and verified by surveyor. 3. Education provided to licensed staff by the Administrator and designee on 5/18/2023 - 5/19/2023 regarding the requirement of providing alternatives to bed rails, and assessments for risk of entrapment. Education provided to staff by the Administrator and designee on 5/19/2023 regarding observations of residents' safety and timely assistance of residents, including resident calling out for assistance. Beginning on 5/20/2023 staff will be educated prior to the beginning of their next shift by the Administrator, DON, or designee regarding the 7 zones of bed entrapment, residents' physical conditions that increase risk of entrapment and the requirement of obtaining consents prior to implementing side rails. Staff will complete a posttest to confirm staffs understanding of education provided and verified by the surveyor. 4. The Director of Nursing or designee (DON was not available for interview but the Administrator) said audits will be will complete audits weekly for 4 weeks, then monthly for 2 months to ensure residents continue to be assessed for entrapment risk, alternatives continue to be provided for enable devices and consents continue to be obtained prior to implementing side rails. The Administrator or designee will complete audits weekly for 4 weeks and monthly for 2 months to ensure staff continue to be educated regarding bed entrapment and factors that increase risk for entrapment prior to providing resident care Findings of these audits will be presented at QAPI Committee meeting monthly for 3 months for review and recommendations as needed. The Director of Nursing is responsible for monitoring and follow-up as needed. The Assistant Director of Nursing and MDS nurse will be responsible for monitoring in the absence of the Director of Nursing. Date of compliance: 05/20//2023 The surveyor verified the implementation of the Plan of Removal as follows. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675554 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Care Center of Nocona 306 Carolyn Rd Nocona, TX 76255 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 0700 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During interviews with 14 (5 LVNs, 6 CNA, 2 maintenance personnel and 1 housekeeper) staff members revealed they were in-serviced on 05/20/23 from 12:00 PM until 4:30 PM and revealed the following: received a pre and posttest on the use of bed rails; they explained the test had questions on the size and type of bedrails, the need for a physician's order, and that a resident had to be assessed for the use of bedrails before the rails could be adjusted to the bed. The staff said there were serious risks for the resident when their bed had side rails and gave examples of choking hazard, and their limbs getting caught up in the rails and causing injuries. Observations on 5/20/23 from 4:00 PM until 5:00 PM revealed 12 resident beds with side rails were assessed by the Certified Occupation Therapy Assistant, 2 were removed. Reviews of the remaining residents with bed rails revealed they had physician's orders, care plans, assessments, and consents for the side rails. Review of the facility's policy titled, Clinical Program Manual Side Rails dated 04/2013, revealed the following: The use of side rails by a patient resident may be a restraint and ordinary depending on functional status and whether or not the side rails restricts freedom of movement. Prior to implementation side rails utilizes is evaluated by the interdisciplinary team to determine the reason for side rails and any alternative device that may be used to achieve the same goal Procedure: .2. Complete the side rail screen 3. Review the information with the interdisciplinary team, include not limited to reason for side rail consideration, ability to move self in bed with a or without a device, ability to transfer or without a device, ability to constantly request for assistance preventing falls and/or entrapment. Review alternatives to side rails but that will meet the identified needs alternatives may include but are not limited to trapeze concave mattress grab bars placing the bed lower to the floor and surrounding the bed with a soft mat bed alarms restorative nursing care to enhance ability to safely safety stand walk or improve bed mobility physical therapy occupational therapy to increase strength and mobility schedule toileting programs increasing visual and our verbal reminders to use call lights for a resident patient able to comprehend the information overview obtain A physician order to for side rails use if identified as a restraint order to include but not limited to reason for use type length of time to be used planned for side rails reduction and or elimination review the risk and benefits of side rails use with the resident patient or family legal representatives complete and provide a copy of the restraint information and consent review the risk and benefits of side rail use with the resident patient and or family legal representative document the plan for site rail reduction on the care plan or if side rails is determined to be a restraint communicate to staff that plan for side rails use and reduction educate staff on side rail use and reduction strategies as needed observe residents patients for the following risk factors of side rails use risk factor may include but not limited to protecting skin over areas of pressure decrease nutrition hydration intake increase difficulty behaviors increase withdrawal symptoms of depression incontinence increase fall risk document ongoing observation and the progress notes documentation to include but not limited to type of side rails length of time used frequency side rails are down resident patient participation and activities and interaction with others residents. On 5/20/23 at 6:30 pm the IJ was lowered The facility remained out of compliance at a severity (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675554 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Care Center of Nocona 306 Carolyn Rd Nocona, TX 76255 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 0700 level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675554 If continuation sheet Page 8 of 8