Inspection·October 27, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the Texas Health and Safety Code Title 2 Health, Subtitle H Public Health Provisions, Chapter 166 Advance Directives, Section 166.083 Form of Out-Of-Hospital DNR order, effective [DATE], revealed, (a) A written out-of-hospital DNR order shall be in the standard form specified by department rule as recommended by the department. (b) The standard form of an out-of-hospital DNR order specified by department rule must, at a minimum, contain the following: . (13) a statement at the bottom of the document, with places for the signature of each person executing the document, that the document has been properly completed. Record review of the Texas Health and Human Services webpage titled, Out of Hospital Do Not Resuscitate Program, updated [DATE], revealed, Frequently Asked Questions for DNR: What happens if the form is not filled out correctly or EMS has doubts about any of the information? Health professionals can refuse to honor a DNR if they think: The form is not signed twice by all who need to sign it or is filled out incorrectly. Record review of the facility's policy titled, Advance Directives, revised 12/2016, revealed, Advance directives will be respected in accordance with state law and facility policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 2 of 17 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 675914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gracy Woods II Living Center 12042 Bittern Hollow Austin, TX 78758 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a clean, comfortable and homelike environment for daily living for 11 of 11 resident rooms ( Residents #8,11,68,48,65,19,47,41,56,78,1 ) reviewed for environmental conditions and for 12 of 12 Residents (Residents #8,11,68,48,65,19,47,41,56,78,1 and #50 ) reviewed for personal equipment in that : 1. The facility failed to maintain fans from being covered in gray fuzzy matter in residents rooms (Residents #8,11,68,48,65,19,47,41,56,78,1 and #50) 2. The facility failed to maintain air conditioning and heating vents in rooms above resident beds from having gray fuzzy matter on them (Residents #8,11,68,48,65,19,47,41,56,78,1 and #50). 3. Nursing staff failed to clean Resident #50's wheelchair as evidenced with dried food residue on the right armrest, on the frame of the wheelchair and on the spokes of the right wheel. 4. The facility failed to provide Resident #4 with a clock in his room in a timely manner when he had requested one for 20 days. These failures could affect residents who reside at the facility and could place them at risk of living in an unsafe, unclean, uncomfortable, and un-homelike environment. Findings include: 1. Observation on 10/23/2022 on initial rounds beginning at 10:37 a.m. of facility revealed in Residents rooms (residents #8,11,68,48,65,19,47,41,56,78,1 and #50 )there were fans with gray fuzzy matter covering the front and back of each fan. During an interview on 10/23/2022 at 11:48 a.m. Housekeeping aide stated she did not know who cleaned the residents fans. She stated she cleaned the floors and bathrooms in the residents rooms. During an interview on 10/23/2022 at 2:00 p.m. the DON, she stated I believe housekeeping cleans the fans in the residents rooms, but not sure because housekeeping duties here are not your typical duties performed. She further revealed that maintenance may also be responsible for cleaning the fans. During an interview on 10/24/2022 at 11:30 a.m. the Housekeeping Director stated she was not sure who cleaned the fans in the residents rooms. During an interview on 10/24/2022 at 1:45 p.m. with CNA F stated , I think housekeeping cleans the residents fans in their rooms. 2. During an observation on 10/26/2022 beginning at 9:30 a.m. of resident rooms 201 a, 202 a,204 a,206 a,309b,501 a,b,506 a,b, 514b,515 a. the vents above residents beds had gray fuzzy matter on them. During an interview on 10/26/2022 at 10:25 a.m. the maintenance director stated he cleaned the vents in the residents rooms monthly if he could . He stated there was no set time or log to identify (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 3 of 17 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 675914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gracy Woods II Living Center 12042 Bittern Hollow Austin, TX 78758 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 when they were to get cleaned. He stated I just clean them, I will clean them right now. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/26/2022 at 10:30 a.m. with the Administrator she stated maintenance should clean the vents above the residents beds. She further revealed the vents should be cleaned to protect the residents from potential respiratory illness. Residents Affected - Some 3. Observation and interview on 10/26/22 at 02:00 PM revealed Resident 50's wheelchair looked like there was dried up food spillage on the right side. The right armrest, the frame of the wheelchair and the spokes of the right wheel had dried up residue. Attempted interview with Resident #50 revealed she did not engage in conversation and did not make eye contact when asking her questions. Interview on 10/26/22 at 02:05 PM with CNA F revealed she started working during January 2022. She stated the armrest and the frame of Resident #50's wheelchair was dirty. CNA F stated she thought the night staff cleaned the wheelchairs but was not sure if it was the aides or maintenance staff. CNA F revealed she had not noticed the spillage on Resident #50's wheelchair but stated it looked like dried food residue. CNA F stated she had not reported it to the charge nurse because she had not noticed it. She stated she had so many residents to get up in the morning and to provide ADL care for during the day she had not noticed. Interview on 10/26/22 at 02:15 PM with LVN D revealed she looked at Resident #50's wheelchair and stated it was not clean. She stated anyone in their right mind, her included, would not be comfortable sitting in a dirty wheelchair. LVN D stated the night CNA's were supposed to clean the wheelchairs as needed. Interview on 10/26/22 at 4:00 PM with the ADON revealed the night aides were responsible for cleaning the resident wheelchairs. The ADON stated they did not maintain a log of when the wheelchairs were cleaned. 4. Record review of Resident #41's face sheet, computer dated 10/26/2022, revealed he was admitted to the facility on admit 1/29/2018 with diagnosis which included age related debility(mobility decline), abnormalities of gate(walking),unspecified dementia(A group of symptoms that affects memory, thinking and interfere with daily life.) Record review of Resident #41's quarterly MDS, dated [DATE] revealed his BIMS (Brief interview for Mental Status) score was an 11 indicating moderately impaired cognition. Record review of facility maintenance record logbook with dates from 6/1/2022 to 10/23/2022 revealed an entry on 10/7/2022 for Resident #41 requesting a wall clock for his room. Entry was not checked with initials to indicate request was completed. Observation on 10/26/2022 at 9:30 a.m. revealed Resident #41 was in his room. No clock was observed in his room. Interview on 10/26/2022 at 11:30 a.m. with Resident #41 stated he wanted a wall clock and asked for one but had not received one. He stated he could not remember when he had asked for the clock. He further stated it would help him know what time it was. Interview on 10/26/2022 at 3:30 p.m. with facility Maintenance Director and Administrator confirmed by viewing the maintenance record logbook with an entry date of 10/7/2022, Resident #41 wanting a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 4 of 17 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 675914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gracy Woods II Living Center 12042 Bittern Hollow Austin, TX 78758 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some wall clock. Maintenance Director and Administrator confirmed by viewing the log that Resident #41 had not received a wall clock as of 10/26/2022. The Maintenance Director stated that Maintenance book should be checked every day and requests resolved within 24 hrs -48 hrs unless something has to be ordered. The Administrator confirmed during interview that she had not checked the maintenance logbook for accuracy. Record review of facility policy titled; Infection Control undated , Purpose: This facility has established the Infection Control Policies and Procedures with guidelines to follow to provide a safe, sanitary and comfortable environment for the residents and employees as well. It is also designed to help prevent the development and transmission of disease and infection. Objective: 2. Maintain a safe, clean and sanitary, comfortable environment for personnel , residents, visitors, and the general public. Record review of facility policy titled: Housekeeping services, dated 2012, Purpose: To promote a safe and sanitary environment which is maintained by a contracted service, by employees of the facility, or a combination of both. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 5 of 17 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 675914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gracy Woods II Living Center 12042 Bittern Hollow Austin, TX 78758 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to make prompt efforts to resolve grievances the resident may have for 1 of 8 Residents (Resident #19) whose records were reviewed for grievances. The facility Social Worker (SW) failed to write and follow up on Resident #19's grievance when she reported 10 items of clothing were missing. This deficient practice could affect residents and place them at risk of their own concerns being left unresolved and lead to misappropriations of resident property. The findings were: Record review of Resident #19's face sheet, computer dated 10/26/2022 revealed Resident #19's was admitted to the facility on [DATE] with diagnoses to include Radiculopathy lumbar region(Lumbar radiculopathy is irritation or inflammation of a nerve root in the low back.), Spinal Stenosis(happens when the space inside the backbone is too small.), other vertebral disc degeneration(A condition where one or more discs in the spine deteriorates due to age, which results in back or neck pain.) Record review of Resident#19's quarterly MDS(The Minimum Data Set (MDS) is a standardized assessment tool that measures health status in nursing home residents.), dated 8/10/2022, revealed her BIMS (Brief interview for Mental Status) score was a 12 indicating moderately impaired cognition. Record review of Resident grievances from 5/1/2022 to 10/23/2022 did not reveal any grievances documented for Resident #19. During an interview on 10/23/2022 at 11:06 a.m. Resident #19 revealed she had reported to the SW that she had missing clothing since she had been at this facility which has been about 6 months. She further revealed she had 10 clothing items which she had provided a copy of drawn pictures to the SW. She said she had told the laundry person who delivers her clothing that she was missing items and had provided a drawn picture to the laundry. She stated there had been no clothing articles found and returned to her as of 10/23/2022. Resident #19 said this was very upsetting to her to not have her clothing returned to her and she became teary eyed during the interview. She stated that all her clothing was marked with her name on them, and she always placed them in a bag with her name on them when she sent them to the laundry. She further revealed that she will be leaving the facility in 4 days and does not feel she will have any clothing articles returned to her before she leaves. During an interview on 10/24/2022 at 12:06 p.m. the facility Social Worker (SW) stated that she could not find any lost clothing for Resident #19. Facility SW stated the facility would replace missing articles of clothing and she had been looking for them in the laundry. She further revealed she was responsible for ensuring grievance forms were completed and that staff followed up on resident concerns. The SW did not produce a grievance form for Resident #19's complaint of clothing missing until after surveyor intervention. The SW stated that if she could not find Resident #19's clothing, that the facility would replace them. She stated she had not written a grievance report, and stated, I have been very busy and just hadn't written one. The SW confirmed telling Resident #19 that the facility would replace items of clothing or provide payment for the value of them, if they were not found. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 6 of 17 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 675914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gracy Woods II Living Center 12042 Bittern Hollow Austin, TX 78758 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and interview on 10/24/2022 at 12:30 p.m. the facility Activity Director escorted surveyor to the laundry. Observation of a clothing rack with unmarked clothing belonging to residents was noted. A laundry personnel, through language interpretation revealed this was lost and found area. She further revealed she knew that Resident #19 had articles of clothing missing and showed surveyor a copy of the articles that were drawn by Resident#19. She stated she had not found any articles of clothing that Resident #19 was missing as of the day of interview. During an interview on 10/24/2022 at 3:30 p.m. the facility Administrator revealed she had heard Resident #19 was missing clothing. The Administrator stated the SW and laundry were aware and were looking for the missing clothing. She further revealed that the facility would replace items of clothing or provide payment for the value of them, if they were not found. Record review of facility policy,dated 2001 and revised April 2017, titled: Grievances/Complaints Filing, policy statement: Residents and their representatives have the right to grievances , either orally or in writing, to the facility staff or to the agency designated to hear grievances( eg, state ombudsman). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 7 of 17 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 675914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gracy Woods II Living Center 12042 Bittern Hollow Austin, TX 78758 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 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 1 of 4 hallways (Hall 400), in that: Residents Affected - Few The Beauty Shop on Hall 400 contained hazardous materials and was open and unlocked. This failure could result in residents becoming ill or injured as a result of exposure to a hazardous resident environment. The findings were: Observation on 10/23/2022 at 2:32 p.m. revealed the Beauty Shop on Hall 400 was unlocked and the door was ajar. Further observation revealed the Beauty Shop contained a container of cleaning liquid which was labeled, Hazardous Material, Harmful if Swallowed, and Keep Out of Reach of Children. Further observation revealed the Beauty Shop contained two aerosol containers labeled, Danger and Keep Out of Reach of Children. During an interview with RN A on 10/23/2022 at 2:34 p.m., RN A affirmed the Beauty Shop on Hall 400 was unlocked, the door was ajar, and the shop contained a container of cleaning liquid which was labeled, Hazardous Material, Harmful if Swallowed, and Keep Out of Reach of Children, as well as two aerosol containers labeled, Danger and Keep Out of Reach of Children. RN A also affirmed that the secure memory care unit was next to the Beauty Shop on Hall 400. During an interview with RN A and the AD on 10/23/2022 at 2:34 p.m., RN A and the AD affirmed residents who wander could encounter the hazardous materials in the unsecured Beauty Shop and become ill or injured. RN A and the AD affirmed the shop was usually locked and stated it may have been accidently left open earlier in the day when donations were delivered to the facility. During an interview with RN A on 10/23/2022 at 2:42 p.m., RN A affirmed that some residents of the secure memory care unit on Hall 400 were independently ambulatory and that all had severe cognitive deficit. During an interview with the AD on 10/25/2022 at 3:36 p.m., the AD reported residents from the secure memory care unit leave secure unit and walk past Beauty Shop to attend group activities. Record review of the facility policy, Hazardous Areas, Devices, and Equipment, revised July 2017, revealed, All hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 8 of 17 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 675914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gracy Woods II Living Center 12042 Bittern Hollow Austin, TX 78758 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 ensure that residents who need respiratory care, are provided such care, consistent with professional standards of practice for 4 of 8 Residents (Resident #11, 68, 47,and 73) reviewed for respiratory care in that: Residents Affected - Some 1. Resident #11 and #68's oxygen concentrator bottle's and n/c did not have a date on it that reflected the facility's changing schedule. 2. Resident #47 had a suction machine at his bedside that was not covered or dated to reflect the facility's changing schedule. 3. Resident #73 was receiving 2 liters of oxygen instead of 4 liters via n/c continuously per physician orders; the oxygen concentrator filter had a layer of lint on it and there was a nebulizer machine on the nightstand that was not secured in a plastic bag when not being used. These deficient practices could affect residents dependent on respiratory care and could contribute to upper respiratory infections and worsening of their physical condition. The findings were: 1. Record review of Resident #11's face sheet, computer dated 10/26/2022, revealed Resident #11 had an initial admission date to the facility on 7/29/2021 with diagnoses to include dysphagia(A condition with difficulty in swallowing food or liquid. This may interfere in a person ' s ability to eat and drink.), adult failure to thrive(Indicates insufficient weight gain), Gerd(Gastro-esophageal reflux disease-A chronic digestive disease where the liquid content of the stomach refluxes into the esophagus, the tube connecting the mouth and stomach.), copd(chronic obstructive pulmonary disease-It is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough.). Record review of Resident #11's Quarterly MDS dated [DATE], revealed Resident #11's BIMS score was 11 indicating moderately impaired cognition. Record review of Resident #11's care plan dated 11/5/2021 and update 8/2/2022: Problem: Respiratory , start 11/5/2021: Resident has diagnosis of copd has potential for respiratory distress and complications due to diagnosis Goal : Resident will not exhibit signs of activity intolerance. Approach: Provide 02(oxygen) as ordered/needed. Observation and interview on 10/23/2022 at 10:37 a.m. revealed Resident #11 had a nasal cannula's with oxygen at 2 lpm on her. Resident #11's oxygen concentrator water bottle and nasal cannula's had a date written on it of 10/13/2022. Resident #11 stated she was on oxygen all the time. She stated she uses a portable oxygen tank when up in her wheelchair and then a concentrator when she is in bed. She further revealed staff place the nasal cannula's on her nose for her and change the bottle on the concentrator. She stated she did not know how often the staff changed the bottle or the nasal cannula's. During an interview on 10/23/2022 at 11:00 a.m. LVN D confirmed Resident #11's disposable oxygen bottle and nasal 11's oxygen concentrator water bottle and nasal cannula's had a date written on it of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 9 of 17 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 675914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gracy Woods II Living Center 12042 Bittern Hollow Austin, TX 78758 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 10/13/2022, indicating when it had been opened or placed. LVN D stated the oxygen bottles and nasal cannulas should have a date written on them to indicate when they are opened or changed. LVN D further revealed night shift change the oxygen bottles and nasal cannulas weekly on Thursdays or when they are empty or dirty, and the date is to be written on the bottles and nasal cannulas. LVN D further revealed this is to prevent infection or bacteria build up. She further revealed there is documentation method in the residents medical records for the nurse to indicate that the cannula or bottle has been changed. During an interview on 10/23/2022 at 2:15 p.m., the DON stated the oxygen bottles for the concentrators and nasal cannulas are to be dated when opened or changed. She further revealed the night shift changes the bottles weekly on Thursday nights. She stated the oxygen bottles and nasal cannulas should be thrown away every 7 days or when they are empty of water in order to keep bacteria from building up. The staff are also expected to place a date on the oxygen bottles and nasal cannulas when a new one is opened. Record review of Resident #11's physician orders dated 8/24/2021 revealed O2(oxygen) @ 2Liters per minute via nasal cannula as needed to maintain O2 saturations greater than 92%. Record review of Resident #68's face sheet computer dated 10/26/2022, revealed Resident #68 had an initial date of admission to the facility on [DATE] with diagnoses which included afib(Atrial fibrillation (A-fib) is an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart.), Hypertension(High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms varies from person to person and generally include unexplained fatigue and headache.),chronic resp failure with hypoxia( Low blood oxygen levels cause hypoxemic respiratory failure.), chronic heart failure( Congestive heart failure (CHF) is a chronic progressive condition that affects the pumping power of your heart muscle.) Record review of Resident #68's Quarterly MDS dated [DATE] , revealed Resident #68's BIMS score was 5 indicating severe cognitive impairment. Observation on 10/23/2022 at 10:15 a.m. revealed Resident #68 was on oxygen. Resident #68's oxygen concentrator water bottle and nasal cannula did not have a date written on it, to indicate when they had been changed. During an interview on 10/23/2022 at 2:15 p.m. , the DON stated the oxygen bottles for the concentrators and nasal cannulas are to be dated when opened. She further revealed the night shift changes the bottles and nasal cannulas weekly on Thursdays. She stated the oxygen bottles and nasal cannulas should be thrown away every 7 days or when they are empty of water in order to keep bacteria from building up. The staff are also expected to place a date on the bottles when a new one is opened. She further revealed the residents suction machines should be covered to prevent dust accumulation. The tubing for the suction machines should be changed every 7 days and dated. 2. Record review of Resident #47's face sheet computer dated 10/26/2022, revealed Resident #47 had an initial date of admission to the facility on 5/27/2022 with diagnoses which included afib,svt, Alzheimer's disease. Generalized anxiety disorder. Record review of Resident #47's Quarterly MDS dated [DATE] revealed Resident #2's BIMS score was 2 indicating severe cognitive impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 10 of 17 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 675914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gracy Woods II Living Center 12042 Bittern Hollow Austin, TX 78758 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 10/23/2022 at 11:22 a.m. revealed Resident #47 suction machine at his bedside that was not covered or dated to reflect the facility's changing schedule. the suction tubing was left open to air and lying on the bedside table uncovered. During an interview on 10/23/2022 at 11:25 a.m. CNA I stated she worked on the 300 hall. She stated the nurses cleaned the residents suction machines. During an interview on 10/23/2022 at 2:15 p.m., the DON stated the nurses clean the residents suction machines. She further revealed they should be covered to prevent dust accumulation. 3. Review of Resident #73's face sheet, undated, revealed her latest return to the facility was on 4/24/21 with diagnoses including acute respiratory infection, unspecified and COPD. Review of Resident #73's quarterly MDS, dated [DATE], revealed her BIMS score was 15 indicative no cognitive impairment and she received oxygen therapy. Review of Resident #73's Care Plan updated on 10/1/22 revealed she had diagnoses of COPD and history of respiratory failure with hypoxia. Some of the staff approaches included to administer medications, nebulizer treatments and oxygen per physician orders. Review of physician orders, dated October 2022, read: May have oxygen at 4 liters via nc continuously. Every shift; Day, Evening, Night. Further review revealed change and label nebulizer treatment tubing and mask every week on Thursday and PRN. Change and label oxygen tubing and clean oxygen concentrator filter every week on Thursday and PRN. Observation and interview on 10/23/22 at 01:45 PM revealed Resident #73 lying in bed with O2 infusing at 2.5 liters via n/c. The tubing was hanging to the floor and it was not in a plastic bag. Further observation revealed the oxygen concentrator filter had a layer of lint on it. Resident #73 stated she did not know when the filter was cleaned and that she had never seen staff clean it. During an interview on 10/23/2022 at 2:15 p.m., the DON stated the nurses clean the residents suction machines. She further stated the suction machines should be covered to prevent dust accumulation. Observation and interview with RN L on 10/26/22 at 4:55 PM revealed Resident #73 was lying in bed receiving O2 via n/c at 2 liters. RN L stated Resident #73 was receiving O2 at 2 liters and further stated the oxygen filter was not clean. Further observation revealed a nebulizer machine on top of the nightstand. RN L stated the nebulizer was not secured in a plastic bag to prevent contamination. RN L stated the oxygen filter and the humidifier were cleaned once weekly. RN L stated Resident #73 used the humidifier all the time; she self-administered and this was probably why it was not secured in a plastic bag. Resident #73 stated she used the nebulizer about 3 times a day and that she was supposed to receive 4 liters of oxygen not 2 liters. RN L reviewed Resident #73's physician orders and stated Resident #73 should receive 4 liters of oxygen via n/c continuously per physician orders but would not verbalize how it would affect the Resident. She stated it should be given at 4 liters per physician orders. Interview on 10/26/22 at 5:10 PM with the ADON revealed Resident #73 was receiving 2 liters of oxygen which meant she was receiving less oxygen than she should be receiving per physician orders. The ADON stated the nebulizer machine should be secured in a plastic bag when not in use to keep it from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 11 of 17 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 675914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gracy Woods II Living Center 12042 Bittern Hollow Austin, TX 78758 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete becoming contaminated. She further stated nursing staff should clean the oxygen concentrator filter weekly to allow free oxygen flow. Record review of facility policy dated 2001 revised August 2019, titled: Cleaning and Disinfection of Environmental Surfaces,Policy statement: Envrionmental surfaces will be cleaned and disinfected according to current CDC recommendations. Section b. Semi-critical items consist of items that may come into contact with mucous membranes(eg respiratory equipment). Event ID: Facility ID: 675914 If continuation sheet Page 12 of 17 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 675914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gracy Woods II Living Center 12042 Bittern Hollow Austin, TX 78758 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to store all drugs and biologicals in locked compartments for 1 of 6 Residents (Resident #76) whose records were reviewed for pharmacy services. Nursing staff failed to store Resident 76's blister pack of Midodrine ( used to treat low blood pressure) in the nurse's medication cart. This deficient practice could affect any resident receiving medications and could result in drug diversion or residents not receiving their medications per physician orders. The findings were: Review of Resident #76's face sheet, undated, revealed she was admitted into the facility on 4/1/20 with diagnoses including Hypertension and End Stage Renal Disease. Review of Resident #76''s physician orders dated October 2022 revealed a prescription for Midodrine, 10 mg, 1 oral NURSES PLEASE SEND WITH RESIDENT EVERY DIALYSIS DAYS FOR DIALYSIS NURSE TO GIVE IT. Once a Day on Tuesday, Thursday, Saturday, FYI night nurse. The start date was 4/20/22 and the order was open ended. Observation and interview on 10/24/22 at 1:30 PM revealed a blister pack of Midodrine prescribed to Resident #76's in her Dialysis binder at the nurse's station. It was not locked. Further observation revealed 7 tablets remaining in the blister pack. Interview with the DON revealed the blister pack containing 7 tablets of Midodrine was inside the Dialysis binder. The DON stated the nurse who last pulled the blister pack for Resident #76's Dialysis treatment date (10/22/22) did not put it back in the medication cart. The DON stated all medications should be under lock and key to prevent drug diversion or other residents taking the medication by mistake. Review of a facility policy, Storage of Medications revised April 2007 read in part: The facility shall store all drugs and biologicals in a safe, secure and orderly manner. 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 13 of 17 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 675914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gracy Woods II Living Center 12042 Bittern Hollow Austin, TX 78758 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 0849 Level of Harm - Potential for minimal harm Residents Affected - Some Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 1 resident (Residents #45) reviewed for hospice services, in that: The facility failed to obtain Resident #45's Physician Certification of Terminal Illness. This failure could place the resident who received hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record review of Resident #45's face sheet, dated 10/27/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Unspecified Dementia with Behavioral Disturbance, Alzheimer's Disease, and Cognitive Communication Deficit. Record review of Resident #45's Quarterly MDS, dated [DATE], revealed the resident was rarely/never understood and a staff assessment for mental status was completed which indicated the resident had short-term and long-term memory problems. Record review of Resident #45's Care Plan, revised 09/04/2022, revealed, [Resident] is under hospice services [related to] DX of Alzheimer's . Record review of Resident #45's Physician Order Report, dated 10/01/2022 to 10/27/2022, revealed, an order dated 05/24/2022, Admit to [hospice company] DX: Alzheimer's Disease . During an interview with the BOM on 10/26/22 at 3:12 p.m., the BOM affirmed the facility did not have a copy of Resident #45's Physician Certification of Terminal Illness and affirmed that Resident #45 began receiving hospice services five months prior. The BOM reported that the Social Worker was responsible for coordination between the facility and hospice providers. Record review of the facility policy, Hospice Program, revised January 2014, revealed, When a resident participates in a hospice program, a coordinated plan of care between the facility, hospice agency, and resident/family will be developed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 14 of 17 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 675914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gracy Woods II Living Center 12042 Bittern Hollow Austin, TX 78758 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 secure memory care common room, in that: 1. The floor under the open refrigerator door was marked with a substance that appeared to be a dried liquid spill. 2. Observation of 3 of 4 Linen Closets revealed the presence of \resident personal clothing and plastic containers overflowing to the floor. 3. The privacy curtains in 2 resident rooms (Residents #56 and #78) had a brown substance on them. 4. There were brown yellow colored stains around the base of toilets in residents rooms 11 of 11 (residents 8, 11, 12, 19, 41, 47, 48, 56, 65, 68, 78) residents' rooms. 5. There was a black substance on tile in 200 hall main shower room. These failures could result in residents, staff, and the public residing, working, and visiting in an environment that was not safe, functional, sanitary, and comfortable. The findings were: 1. Observation on 10/23/2022 at 2:48 p.m. revealed a refrigerator was located in the common room of the secure memory care unit. Further observation revealed the floor under the open refrigerator door was marked with a substance that appeared to be a dried liquid spill, approximately 12 inches by 8 inches and rusty brown in color. During an interview with CNA B on 10/23/2022 at 2:48 p.m., CNA B affirmed the floor under the open refrigerator door was marked with a substance that appeared to be a dried liquid spill. CNA B reported that all staff were responsible for cleaning liquid spills at the time of the spill, and affirmed liquid spills had the potential to be a fall hazard for staff and residents or to encourage insect activity. During an interview with the Administrator on 10/25/2022 at 4:25 p.m., the Administrator affirmed the facility should provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. 2. During an observation on 10/23/2022 at 11:19 a.m. of Linen Closet #1 in hall 300 revealed the presence of bagged clothing , plastic bins overflowing to floor with socks and personal clothing of residents. During an interview and observation on 10/23/2022 at 11:19 a.m. the HR Director stated, the staff knows that the linen closet is for the storage of cleaned linen, and bagged clothing , plastic bins overflowing to floor with socks and personal clothing of residents should not happen. During an interview on 10/24/2022 at 11:30 a.m. the Housekeeping Supervisor confirmed Linen Closet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 15 of 17 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 675914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gracy Woods II Living Center 12042 Bittern Hollow Austin, TX 78758 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some #1 in hall 300 revealed the presence of bagged clothing , plastic bins overflowing to floor with socks and personal clothing of residents. The Housekeeping Supervisor stated, we clean and straighten the linen closets everyday, but nursing staff does not always help us keep it clean and clutter free. 3. During an observation on 10/26/2022 at 9:40 a.m. in resident rooms (Residents #56 and #78), the resident privacy curtains had 2 brown substance's midway down on the curtain, approximately the size of a quarter. During an observation and interview on 10/26/2022 at 10:00 am the facility ADON confirmed by observation that resident rooms (Residents #56 and #78), the resident privacy curtains had brown substance on them. The ADON further revealed maintenance changed the privacy curtains but did not know the schedule. During an interview on 10/26/2022 at 10:30 a.m. with Maintenance Director and Adminsitrator both confirmed that resident privacy curtains should be clean. The Maintenance Director stated he, changed the curtains whenever they were dirty. The Maintenance Director stated the staff would tell him if the curtains were dirty and he would change them. The Maintenance Director further revealed he did not know the two curtains (Residents #56 and #78) were dirty. The Maintenance Director stated he did not have a set schedule or log. The Maintenance Director further revealed it took him about a full month to change all of the privacy curtains in the facility. The Administrator stated, a schedule log, would be started. 4. During observations on 10/26/2022 of residents rooms(residents 8,11,12,19,41,47,48,56,65,68,78), brown yellow colored stains around the bases of toilets in 11 of 11 residents rooms reveiewed for cleanliness. During an interview on 10/26/2022 at 10:30 a.m. with Maintenance Director stated he was aware of the caulk around the residents toilets needing to be changed. He confirmed by observation the brown yellow colored stains around base of toilets in residents rooms was present and needed to be cleaned and repaired. 5. During an interview on 10/26/2022 at 11:15 a.m. with Resident #12 she informed surveyor that there was a black substance on tile in 200 hall main shower room. She stated she received her showers in the shower room and she did not like the way it looked. I am concerned it is mold. She stated she could not remember who she had told about it but she said she did. During an observation on 10/26/2022 at 11:30 a.m. there was a black substance on 6 of the shower tiles located at the base of the shower stall in the 200 hall main shower room. The Facility Treatment Nurse was present at time of observation and confirmed by observation black substance on tile in 200 hall main shower room. The Facility Treatment Nurse stated, I do not know what that is and it does not come off when rubbed. During an interview on 10/26/2022 at 11:45 a.m. with the Maintenance Director, he said he did not know anything about a black substance on tile in 200 hall main shower room. The Maintenance Director stated he would fix it. He further revealed there is a maintence log book at the nrses station for the staff to log in any repairs or concerns. Record review with the Maintenance Director revealed no entry for black substance on tile in 200 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 16 of 17 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 675914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gracy Woods II Living Center 12042 Bittern Hollow Austin, TX 78758 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 0921 hall main shower room. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's Policies and Procedures with guidelines to follow to provide a safe, sanitary and comfortable environment for the residents and the employees as well. It is also designed to help prevent the development and transmission of disease and infection. Residents Affected - Some Record review of facility policy, dated 2012 and titled: Housekeeping Services revealed: Purpose: To promote a safe and sanitary environment which is maintained by a contracted service, by employees of the facility, or a combination of both. Policy: 1. Frictional Cleaning A. Thorough scrubbing will be used for all environmental surfaces that are being cleaned in resident care areas. III. Routine Cleaning of Horizontal Areas A. In resident care areas, cleaning of non-carpeted floors and other horizontal surfaces will be done daily and more frequently if spillage or visible soiling occurs. Record review of the facility policy, Quality of Life -Homelike Environment, revised May 2017, revealed, Residents are provided with a safe, clean, comfortable, and homelike environment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 17 of 17