Inspection·November 21, 2024

F 0644 Monitor for signs of depression, suicidal ideation and insomnia. 09/01/2023 Level of Harm - Minimal harm or potential for actual harm 3. Residents Affected - Some Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every morning and at bedtime for Agitation/Aggression, order date 09/18/2024 4. Depakote Oral Tablet Delayed Release 500 MG (Divalproex Sodium) Give 1 tablet by mouth three times a day related to UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY (F03.90), order date 10/16/2024 5. trazodone HCl Oral Tablet 50 MG (Trazodone HCl) Give 25 mg by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE (F33.1) give 1/2 a 50mg tab to = 25mg. GDR attempt order date 12/17/2023 Review of Resident #13's Care Plan revised on 11/11/2024 reflected the following: Focus: Resident is on an antidepressant medication r/t Depression and insomnia. Date Initiated: 09/01/2023. Goal: Resident #13 will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Date Initiated: 09/01/2023. In an interview on 11/21/2024 on 11:51 a.m., MDS coordinator stated, The resident has a diagnosis of major depressive disorder. I will review the chart for a 1012 form (form used to determine whether the individual has a primary dementia diagnosis or if the individual has a mental illness diagnosis) and get back with you. In an interview on 11/21/2024 on 12:26 p.m., MDS coordinator stated she was responsible for PASRR's, I looked in Resident #13's chart and could not find a 1012 form. There are some diagnoses in the chart that would warrant a 1012 form. She also stated A negative result in not having a current 1012 form is that the resident has not received PASRR services and may not be receiving psych services if needed . Review of the facilities policy and procedures titled PASRR Clinical Policy, not dated, reflected the following [in part]: Purpose: The PASRR level 1 (PL1) Screening Form is designed to identify persons who are suspected of having Mental Illness (MI), Intellectual Disability (ID) of a Developmental Disability (DD) also referred to as Related Conditions. The PASRR Evaluation (PE) is designed to confirm the suspicion of MI, ID or DD/RC and ensure the individual is placed in the most integrated residential setting receiving the specialized services needed to improve and maintain the individual's level of functioning. Section C; PASRR Screen (Screener) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675554 If continuation sheet Page 2 of 20 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 11/21/2024 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 0644 INTENT: This section to be completed for resident's suspected of having Mental Illness. Level of Harm - Minimal harm or potential for actual harm Identify diagnoses: Review the medical record, if available, for diagnoses. Medical record sources can include but are not limited to verbal interview with the resident, or LAR, observation, progress notes, Annual Physical Exam, the most recent History and Physical, hospital discharge summaries or diagnosis list. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675554 If continuation sheet Page 3 of 20 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 11/21/2024 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure all Preadmission Screening and Resident Review (PASARR) Level I (PL1) Screening residents diagnosed with mental illness were provided with a PASARR Level II (PE) Screening for 1 of 2 residents (Resident #3) reviewed for a mental illness, intellectual disability, or developmental disability. Residents Affected - Some The facility failed to ensure Resident #3, with an initial admission date of 03/22/18, had a diagnosis of mental illness and a PASARR Level II (PE) screening was not completed. This failure placed residents at risk of mental health needs not being met. The findings included: A record review of Resident #3's admission Record, dated 11/21/24, revealed Resident #3 had an initial admission date of 03/22/18 and the latest admission date of 04/25/24. Resident had a primary diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris (the blood vessels that carry oxygen and nutrients from the heart to the rest of the body become thick and stiff). The resident had secondary diagnosis including Unspecified Dementia, unspecified severity, with other behavioral disturbance (a group of symptoms that affects memory, thinking and interferes with daily life); Bipolar Disorder (a mental health condition that causes extreme mood swings); Schizophrenia (a serious mental health condition that affects how people think, feel and behave); Schizoaffective Disorder, Bipolar Type (a mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder). A record review of a PASARR Level I (PL1) Screening, dated 04/25/24, indicated Resident #3 had no evidence of mental illness. No PASARR Level II (PE) Screening or a form 1012 (Mental Illness/Dementia Resident Review) was found in the clinical record. A record review of the Resident # 3's Quarterly MDS assessment, dated 09/11/24, revealed Active Diagnosis of Anxiety Disorder, Bipolar Disorder, and Schizophrenia. A record review of Resident # 3's Care Plan, with a completion date of 09/26/24, indicated Resident #3 uses psychotropic medications related to schizoaffective disorder, bipolar. In an interview on 11/21/24 at 11:51 am, the MDS Coordinator stated she was responsible for the PASSAR evaluations. She said Resident #3 did not have a primary diagnosis of dementia. She said Resident #3 should have had a PASSAR Level II evaluation completed, or a 1012 form completed on record as he had the qualifying diagnosis. She said there was no evidence Resident #3 had a 1012 form in his record. She said a potential negative outcome of this failure would be a resident might not receive PASSAR services if they were eligible. In an interview on 11/21/24 at 12:38 pm, the Chief Nursing Officer, stated she had just spoken with the MDS Coordinator and was aware of Resident #3 not having a PASSAR Level II evaluation. She said a potential negative outcome would be the resident would not receive specialized services . Record review of the facility policy PASRR Clinical Policy, Level 1, not dated, revealed the following [in part]: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675554 If continuation sheet Page 4 of 20 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 11/21/2024 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 0645 Purpose: If documentation entered on the PL1 indicates MI/ID/DD, a PE must be completed. Level of Harm - Minimal harm or potential for actual harm Section C Steps for Assessment: 7. If Alzheimer/Dementia is the primary diagnosis and there is a MI diagnosis no PE is needed. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675554 If continuation sheet Page 5 of 20 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 11/21/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 2 of 18 residents (Residents # 36, and #38) reviewed for care plans as follows: 1. Resident #36 did not have a comprehensive care plan completed within 14 days of admission. Resident #36 was admitted on [DATE] and his first comprehensive care plan was not completed until 10/6/24. 2. Resident #38 was admitted on [DATE] and did not have a comprehensive care plan completed until the CNO was notified on 11/19/24. Her care plan was then completed on 11/20/24. This failure could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial needs to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings include: Resident # 36 Record review of Resident #36's face sheet dated 11/20/24 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: chronic pancreatitis (inflammation of the pancreas), essential hypertension (high blood pressure), gastro esophageal reflux disease without esophagitis (acid reflux), benign prostatic hyperplasia without lower urinary tract symptoms (frequent urination), generalized anxiety disorder (anxiety), major depressive disorder (depression), and schizophrenia (a disorder that affects a person's ability to think ). Record review of Resident #36 revelaed his comprehensive care plan was not completed until 11/20/24. Record review of Resident #36 admission MDS revealed it was completed on 8/13/24, Quarterly MDS was completed on 11/13/24. Observation of Resident #36 on 11/19/24 at 2:54 PM, revealed that Resident #36 voiced concerns about his mood, choices, dental, nutrition, pain management, and genitourinary needs. Record review of Resident #36's care plan dated 10/6/24 indicated that these needs were being met. However, it was noted that his initial comprehensive care plan was not competed until 10/6/24. During an interview with the CNO on 11/21/24 at 12:38 PM, she indicated Resident #36 had a baseline care plan completed, but not a comprehensive care plan completed until 10/6/24. Resident # 38 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675554 If continuation sheet Page 6 of 20 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 11/21/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #38's face sheet dated 11/19/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: chronic pain, glaucoma (an eye condition that can cause blindness), sensorineural hearing loss (hearing loss), hypertension (high blood pressure), gastro esophageal reflux disease without esophagitis (acid reflux), osteoarthritis (arthritis of the joints), repeated falls, amnesia (memory loss), dizziness and giddiness (dizziness and unsteadiness), and overactive bladder (sudden need to urinate). Record review of Resident #38 dated 11/19/24 revealed there had been no comprehensive care plan completed for Resident #38 who was admitted on [DATE]. Record review of Resident #38 admission MDS revealed it was completed on 10/27/24. During an interview with the CNO on 11/20/24 at 3:36 PM, she stated there is not a comprehensive care plan for Resident #38. She stated that it is her expectation for care plans to be completed in the allowed time frame. She further stated that she had spoken with the MDS coordinator and instructed her that a care plan needed to be completed. Record review of the facility's policy, Care Plans- Comprehensive Person-Centered, revealed the following documentation [in-part]: Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: #12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675554 If continuation sheet Page 7 of 20 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 11/21/2024 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interviews and record reviews, the facility failed to provide the services of an RN for 8 consecutive hours 7 days a week for 22 days out of 79 days and employ a full time DON for 19 of 79 days reviewed for RN coverage from September 2024 to November 2024. The facility failed: - to have an RN for 8 consecutive hours 7 days a week for 22 days from September 1, 2024, through November 18, 2024. - to employ a full time DON for 19 of 79 days from September 1, 2024, through November 18, 2024. This failure placed the residents at risk for altered physical, mental, and psychological well-being due to decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff. Findings included: Review of daily staffing data revealed the facility did not provide the services of an RN on the following dates: September 1, 2024, September 2, 2024, September 3, 2024, September 4, 2024, September 5, 2024, September 14, 2024, October 6, 2024, October 27, 2024, November 1, 2024, November 4, 2024, November 5, 2024, November 6, 2024, November 7, 2024, November 8, 2024, November 11, 2024, November 12, 2024, November 13, 2024, November 14, 2024, November 15, 2024, November 16, 2024, November 17, 2024, November 18, 2024. Review of daily staffing data revealed the facility did not employ a full time DON on the following dates: September 1, 2024, September 2, 2024, September 3, 2024, September 4, 2024, September 5, 2024, November 1, 2024, November 4, 2024, November 5, 2024, November 6, 2024, November 7, 2024, November 8, 2024, November 11, 2024, November 12, 2024, November 13, 2024, November 14, 2024, November 15, 2024, November 16, 2024, November 17, 2024, November 18, 2024. During an interview on 11/19/24 at 8:35 AM, the CNO stated the facility currently did not have a DON. She stated a DON had been hired, the facility was waiting for her to work out her notice at her former job. The CNO stated the facility currently did not have consistent weekend RN coverage. During an interview on 11/21/24 at 8:31 AM, the Administrator stated staff was notified when an RN will not be in building via group text. The Administrator denied experiencing an issue of a resident needing the services of an RN and not receiving those services. She explained the facility subscribed to a telehealth service and had 24-hour access to a corporate RN. The Administrator stated in an emergency, residents were transferred to the hospital or the physicians, who live close by, had no problem coming to the facility when needed. The Administrator stated she did not feel no RN in the building had a negative effect on residents due to access to the corporate RN and other resources available. She stated her expectations were for the new DON to start next week as scheduled. The Administrator stated she had plans to be more diligent on getting weekend RN coverage and increase the PRN RN pool. She explained the facility recruits via online advertising and word of mouth. During a group interview on 11/21/24 at 10:17 AM, LVN D and MA E stated they felt the residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675554 If continuation sheet Page 8 of 20 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 11/21/2024 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many were not affected if an RN was not in the building. LVN A stated when a resident needs service only an RN can perform, one of the weekend RNs would come in or the resident would be transferred to the hospital. LVN D stated staff was not notified when an RN would not be in the building but had got used to it. During an interview on 11/21/24 at 12:38 PM, the CNO stated the issue with RN coverage was on Monday thru Friday the facility did not have a full time DON. The facility was in the process of transitioning from one DON to another. She stated it was difficult to find staff in a rural area. The CNO stated a DON had been hired and was scheduled to start working the following Monday, but the weekends seemed to be an issue. She stated she had reached out to some of the PRN RN's and begged them to accept the DON position, but they had other jobs and did not want to commit to full time employment with the facility. The CNO explained the nursing staff were aware when an RN would not be in the building because the schedule would indicate when an RN was not available to be in the building. The CNO stated If a resident required the skill level of an RN and one was not in the building, the resident would be transferred to the local emergency department. The CNO stated the facility received assistance in recruiting staff from the bank that owns the building. She explained the bank paid for advertising on a major online recruitment site. Review of the facility policy, titled Staffing, undated, revealed Policy Interpretation and Implementation 1. Licensed nurses and certified nurse assistants are available 24 hours a day to provide direct resident care services. At a minimum, the facility must maintain a ratio (for every 24-hour period) of one licensed nursing staff person for each 20 residents or a minimum of .4 licensed-care hours per resident day. A registered nurse (RN) must be onsite 8 consecutive hours a day, 7 days a week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675554 If continuation sheet Page 9 of 20 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 11/21/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record 1 of 13 residents. (Resident #13) reviewed for unnecessary psychotropic medications. The facility failed to ensure Resident #13 had a proper diagnosis to receive medication (Depakote and Ativan) as ordered. This failure could affect residents who received medications in the facility and put them at risk for adverse consequences such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. The findings included: Record review of Resident #13's face sheet, dated 05/23/2023, revealed a [AGE] year-old female, who was admitted into the facility on [DATE] with a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (confusion without behaviors), repeated falls, muscle weakness, unsteadiness on feet and lack of coordination. Record review of Resident #13's diagnosis report revealed she was diagnosed with major depressive disorder on 09/01/2023 and anxiety disorder effective 11/21/2024. Record review of Resident #13's MDS, dated [DATE] revealed the residents Brief Interview for Mental Status was coded as a 0, resident is rarely/never understood; Section E Behaviors revealed: Potential indicators of psychosis including hallucinations and delusions worsening since last MDS assessment; Section N Medications revealed: Resident #13 is taking Antipsychotic, antianxiety, antidepressant, Antipsychotics were received on a routine basis. Record review of Resident #13's Care Plan last reviewed on 11/11/24 did not indicate any anti-psychotic medications or needs for such medications. Record review of Resident #13's physician order summary revealed the following: 1. Depakote Oral Tablet Delayed Release 500 MG(Divalproex Sodium) Give 1 tablet by mouth three times a day related to UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE,MOOD DISTURBANCE, AND ANXIETY with an order start date of 10/16/2024 and no end date. 2. Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every morning and at bedtime for Agitation/Aggression with an order start date of 09/18/2024 and no end date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675554 If continuation sheet Page 10 of 20 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 11/21/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm In an interview on 11/21/24 at 12:13 PM, Regional Nurse Consultant stated that dementia is not an appropriate diagnosis for Depakote medication administration. She further stated that agitation/aggression is not an appropriate diagnosis for Ativan medication. She stated we need a true diagnosis, that is a symptom not a diagnosis. She stated that it was the responsibility of the MDS coordinator to ensure diagnoses were input based on the physician notes. Residents Affected - Some In an interview on 11/21/24 at 12:38 PM, the CNO stated that diagnoses used for Depakote and Ativan are not appropriate diagnoses for those medications. She stated, mood stabilization is not a medical diagnosis, but mood disorder is a diagnosis, but is not used. She stated that it is the responsibility of the MDS coordinator to ensure proper diagnoses are in use. Record review of facility policy Antipsychotic Medication Use not dated revealed the following [in part]: Policy Statement: Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. Policy Interpretation and Implementation: 1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. 6. Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident. 7. Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (current or subsequent editions): a. Schizophrenia; b. Schizo-affective disorder; c. Schizophreniform disorder; d. Delusional disorder; e. Mood disorders (e.g. bipolar disorder, depression with psychotic features, and treatment refractory major depression); f. Psychosis in the absence of dementia; g. Medical illnesses with psychotic symptoms and/or treatment-related psychosis or mania (e.g., high-dose steroids); h. Tourette's Disorder; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675554 If continuation sheet Page 11 of 20 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 11/21/2024 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 0758 i. Huntington Disease; Level of Harm - Minimal harm or potential for actual harm j. Hiccups (not induced by other medications); or k. Nausea and vomiting associated with cancer or chemotherapy. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675554 If continuation sheet Page 12 of 20 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 11/21/2024 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 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, distribute, and serve food in accordance with professional standards for food service safety, for 38 of 40 residents as evidence by : The facility failed to ensure: A. The low temperature dishwashing machine did not have a chemical sanitizer and the dietary staff failed to check the chlorine sanitizer content to ensure the dish washing machine was operating correctly to clean and sanitize the dishes consistently each meal; B. The 2 food carts were soiled with dust and food crumbs; C. Open food items were not placed in sealed containers and dated; D. The ice machine had mold at the top of the ice tray; E. The window seal including the window unit air conditioner was soiled with dust and food crumbs; F. The stove and oven were soiled with food and grease; G. The freezer in the storage room with soiled with dust and food crumbs; H. The floors in the storage room were soiled with dust, dirt, and food crumbs. The facility's failure could place residents receiving oral nutritional intake at risk for foodborne illness and a decline in health status. The findings included: On 11/19/24 at 8:45 AM, during the initial tour of kitchen, the container of chlorine chemical sanitizer to the low temperature dishwashing machine was empty, 2 food carts were soiled with dust and food crumbs, the ice machine had mold at the top of the ice storage area, in the freezer there was a box of biscuits opened to the air and was not sealed or dated, in the refrigerator there was a bag of shredded cheddar cheese open to the air and not sealed or dated, the window seal and the window air conditioner was covered with dust and food crumbs, the stove and oven were soiled with dried food and grease, the freezer in the dry foods storage room was soiled with dirt and food crumbs, and the floor in the dry foods storage room was soiled with dirt and food crumbs. In interviews on 11/19/24 at 8:50 am, Dietary [NAME] A said she did not know how to test the dish washing machine and did notn't know it was out of chemical sanitizer and had never been trained. Dietary [NAME] B said she didn't know how to test the dishwashing machine and didn't know it had been out of chemical sanitizer and had never been trained. Dietary [NAME] C said the chemical sanitizer had been out less than a week and said he reported it to the Maintenance Director. Dietary [NAME] C said he does not test the dish washing machine between meals but knew how to test it. Upon request, Dietary [NAME] C tested the machine and the chlorine registered at 0 ppm, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675554 If continuation sheet Page 13 of 20 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 11/21/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many In an interview on 11/19/24 at 9:30 am, the Administrator said the facility has not had a dietary manager since 10/01/24. She was not aware the chemical sanitizer was out. She said the company had not paid the vendor yet and was unable to order anymore chemicals until it was paid but had been paid today. She said the Maintenance Director had gone to a sister facility to pick up some chemical sanitizer. In an interview on 11/19/24 at 10:00 am, the Maintenance Director was in the kitchen working on attaching the chemical sanitizer to the dishwashing machine, he said that he notified corporate on 10/14/24 the facility was getting low on the chemical sanitizer. He said he was not for sure had long it was out, but it was not very long. In an observation and interview on 11/20/24 at 9:50 am, Dietary [NAME] C was asked to check the dish washing machine. It tested at 10 ppm (minimum was 50 ppm). The chemical sanitizer was attached to the dish washing machine. He said that it tested at 50 ppm yesterday when the Maintenance Director tested it after attaching the new chemical sanitizer. In an observation and interview on 11/20/24 at 11:59 am, the Maintenance Director tested the dish washing machine and it tested at 0 ppm, he said that it tested at 50 ppm yesterday after he attached the chemical sanitizer he got yesterday. He said the facility would switch to paper products until it was fixed and have the vendor come and service the machine. In an observation and interview on 11/21/24 at 2:41 pm, the vendor was in the facility working on the dish machine, they said that a squeeze tube had failed and was replaced. They said the dish machine was working correctly. In an interview on 11/21/24 at 2:55 pm, the Administrator said the facility was getting some new chemical sanitizer and would continue to use paper products until it comes in. She said there have been no reports of residents having symptoms of food born illnesses. She said there hads not been a Dietary Manager at the facility, officially since 10/01/24 as she had been out on FMLA prior to that date. She said Dietary [NAME] A is currently working on obtaining her certification to be a Dietary Manager. She said it was her expectation for the dish washing machine to be tested at every meal to ensure it was properly sanitizing the dishes. She said it was her expectation for the kitchen to be cleaned and all appliances clean and in good working order. She said theses failures had the potential for food born illnesses, poor food quality and unsanitary conditions. Record review of the facility policy Dishwashing Machine Use, not dated, revealed the following [in part]: Policy Statement: Food service staff required to operate the dishwashing machine will be trained on all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation. Policy Interpretation and Implementation: 4. Dishwashing machine chemical sanitizer concentrations and contact times will be as follows: Chlorine, 50-100 ppm. 6. Corrective action will be taken immediately if sanitizer concentrations are too low. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675554 If continuation sheet Page 14 of 20 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 11/21/2024 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 0812 Record review of the facility policy Sanitization, not dated, revealed the following [in part]: Level of Harm - Minimal harm or potential for actual harm Policy Statement: The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation: Residents Affected - Many 1. All kitchen, kitchen areas and dining areas shall be kept clean, free of litter and rubbish and protected from rodents, roaches, flies and other insects. 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use of proper cleaning. 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. 8. Dishwashing machines must be operated using the following specifications: Low-Temperature Dishwasher (Chemical Sanitization) b. Final rinse with 50 parts per million (ppm) hypochlorite (chlorine) for at least 10 seconds. 12. Ice machines and ice storage containers with be drained, cleaned and sanitized per manufacturer's instructions and facility policy. 17. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. Record review of the Food and Drug Administration Food Code, dated 2017, specified [in part]: 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675554 If continuation sheet Page 15 of 20 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 11/21/2024 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 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 maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents reviewed for infection control. (Resident #9, #28, and #91). Residents Affected - Some 1. The facility failed to place Resident #9 who had a gastrostomy tube (tube into stomach thru abdomen) on EBP. 2. The facility failed to place Resident #28 who had a wound on EBP. 3. The facility failed to place Resident #91 who had a PICC (Peripherally inserted central catheter) on EBP. These failures could place residents at risk for cross-contamination, increased risk of infection and the spread of infection. The findings included: Resident #9 Record review of Resident #9's electronic face sheet dated 11/21/24 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: unspecified sequelae of cerebral infarction (stroke), dysphagia (difficulty swallowing), polyosteoarthritis (joint stiffness and pain) and lack of coordination. Record review of Resident # 9's MDS, dated [DATE], revealed resident's BIMS (Brief Interview for Mental Status) was not conducted due to resident is rarely/never understood, he received gastrostomy tube feedings, and he was always incontinent of bowel and bladder. Record review of Resident #9's physician order summary dated 11/20/24 revealed the following: Check for tube placement prior to each flush, medication administration tube feeding changes, etc. by air bolus auscultation and aspiration of stomach contents as needed for maintain patency. Clean g-tube site with NS, apply drainage sponge QD, monitor for s/s infection every night shift. Cleanse g-tube stoma with wound cleanser pat dry, apply Anacept gel, leave open to air every day shift. No physician order found for enhanced barrier precautions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675554 If continuation sheet Page 16 of 20 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 11/21/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #9's comprehensive person-centered care plan last review date of 10/06/2024 revealed the following: Focus: Resident #9 requires tube feeding and is NPO, related to Dysphagia, Swallowing problem, Weight Loss. Residents Affected - Some Goal: Resident #9 will remain free of side effects or complications related to tube feeding through review date. Interventions: Provide local care to G-Tube site as ordered and monitor for signs and symptoms of infection. There was no focus, goal, or intervention for enhanced barrier precautions. Observation on 11/19/24 at 9:41 AM of Resident #9's room revealed no posted EBP sign outside of door nor in resident room, no personal protective equipment (gown or gloves) available for staff use. Resident #28 Record review of Resident #28's electronic face sheet dated 11/21/24 reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: senile degeneration of brain (mental deterioration), repeated falls, aphasia (difficulty speaking), altered mental status and supraventricular tachycardia (irregular heartbeat). Record review of Resident #28's MDS, dated [DATE], revealed resident's BIMS (Brief Interview for Mental Status) score of 99, unable to complete the interview, she has one stage 4 (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer and she was always incontinent of bowel and bladder. Record review of Resident #28's physician order summary dated 11/20/24 revealed the following: Left hip Stage 3 Cleanse with Dermal wound cleanser, pat dry with 4x4 gauze, apply Collagen Hydrogel then apply Calcium Alginate with Silver 2x2, then cover with 4x4 Hydrocellular foam dressing on Monday, Wednesday and Friday and PRN every day shift every Mon, Wed, Fri for wound care. No physician order found for enhanced barrier precautions. Record review of Resident #28's care plan with last review date of 10/15/24 revealed the following: Focus: Resident #28 has a stage 4 pressure ulcer to the sacrum and has potential for further pressure ulcer development related to End Stage Senile Degeneration of Brain, Muscle wasting/atrophy. Goal: Resident #28's Pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions: Monitor/document/report to MD PRN changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size (length X width X depth), stage. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675554 If continuation sheet Page 17 of 20 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 11/21/2024 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 0880 There was no focus, goal, or intervention for enhanced barrier precautions. Level of Harm - Minimal harm or potential for actual harm Observation on 11/19/24 at 11:37 AM, of Resident #28's room revealed no posted EBP sign outside of door nor in resident room, no personal protective equipment (gown or gloves) available for staff use. Residents Affected - Some Resident #91 Record review of Resident #91's electronic face sheet dated 11/21/24 reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: infection and inflammatory reaction due to internal fixation device of spine (infection due to implant), essential hypertension (high blood pressure), difficulty walking, muscle weakness and low back pain. Record review of Resident #91's MDS, dated [DATE], revealed resident's BIMS (Brief Interview for Mental Status) score of 13 (normal cognitive function), and PICC access with antibiotic infusion. Record review of Resident #91's physician order summary dated 11/20/24 revealed the following: Cefepime HCl Intravenous Solution Reconstituted 2 grams (Cefepime HCl) Use 2 gram intravenously one time a day for infection of internal fixator Infuse 2 grams IVPB to PICC LINE to right upper arm. Daptomycin Intravenous Solution Reconstituted 350mg (Daptomycin) Use 350 mg intravenously every 48 hours for surgical wound until 12/03/2024 23:59 infuse to central line in RIGHT upper arm. Observation on 11/19/24 at 11:31 AM, of Resident #91's room revealed no posted EBP sign outside of door nor in resident room, no personal protective equipment (gown or gloves) available for staff use. In an interview on 11/21/24 at 12:15 PM, LVN D stated that EBP is used for residents that have a PICC line, wound, catheter or g-tube. She stated that her understanding of EBP means the nurses must use gown and gloves when performing patient care. Sometimes a mask depending on precautions ordered. She stated that she can identify residents on EBP by looking at the orders or looking in the resident's chart. She also stated that lack of use of EBP could lead to cross contamination. In an interview on 11/21/24 at 12:20 PM, MA E stated EBP is use of gown and gloves for extra precautions for residents who have a PICC, catheter or g-tube. She stated that she can identify residents who are on EBP by a paper on the resident's door or order in the chart. She further stated, The gowns and gloves are on the linen cart or in the supply closet. She stated lack of use of EBP could allow transfer of one resident's infection to another. In an interview on 11/21/24 at 12:25 PM CNA F stated EBP is when you put on the gowns and stuff. He also stated this is only my 6th shift here and this is the first one(EBP sign) I've seen. I have to go to the linen cart or supply closet to get gown and gloves. He stated that lack of EBP use could lead to spreading infection to others. In an interview on 11/21/24 at 12:38 PM CNO stated EBP glove and gown per CDC requirements should be in effect any time a resident has a tracheostomy, g-tube, foley catheter, or wound. She stated EBP signage was posted outside resident's rooms on morning of survey day 2. She further stated, I put it up when I realized it wasn't there. We have gloves and gowns, readily available. I have a box of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675554 If continuation sheet Page 18 of 20 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 11/21/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm PPE in the DON office. CNO also stated that lack of signage in facility was oversight and lack of consistent leadership. CNO stated an adverse outcome of lack of EBP use could lead to potential spread of infectious disease. Record review of facility policy Enhanced Barrier Precautions not dated revealed the following [in-part]: Residents Affected - Some Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Policy Explanation and Compliance Guidelines: 1. Prompt recognition of need: c. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. 2. Initiation of Enhanced Barrier Precautions a. Nursing staff may place residents with certain conditions or devices on enhanced barrier precautions empirically while awaiting physician orders. b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. ii. Infection or colonization with any resistant organisms targeted by the CDC and epidemiologically important MDRO when contact precautions do not apply. 3. Implementation of Enhanced Barrier Precautions a. Make gowns and gloves available immediately outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray. 4. High-contact resident care activities include: a. Dressing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675554 If continuation sheet Page 19 of 20 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 11/21/2024 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 0880 b. Bathing Level of Harm - Minimal harm or potential for actual harm c. Transferring d. Providing hygiene Residents Affected - Some e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes h. Wound care: any skin opening requiring a dressing 7. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until the wound heals or indwelling medical device is removed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675554 If continuation sheet Page 20 of 20