Inspection·March 20, 2025

F 0550 chronic pain. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #93's Quarterly MDS dated [DATE] revealed Resident #93 had a BIMS score of 15 indicating intact cognitive Response. Residents Affected - Some Observation of 300 hall on 03/18/2025 at 09:15 a.m., revealed CNA D did not knock on Resident #81's and Resident #93's door before entering. Observation of 200 hall on 03/19/2025 at 1:17 p.m., revealed RA C walked into Resident #12's room without knocking. During an interview with Resident #81 on 03/19/2025 at 10:25 a.m., he said that staff do not always knock on his door. He said there were times he would be in the bathroom and not hear the staff knock and the staff come into his room and open the bathroom door without knocking. He said it upsets him that staff just open the bathroom door when he is going to the bathroom and invading his privacy. He said he wanted staff to knock on his door and the bathroom door all the time. During an interview with Resident #93 on 03/20/2025 at 8:30a.m., he said that staff do not always knock. He said that he would like for staff to knock all the time. He said he gets irritated when staff just walk into his room. He said especially when he had the door closed. During an interview with Resident #12 on 03/20/2025 at 10:29 a.m., she said that staff do not always knock on her door. She said that she wanted them to knock all the time because that was what people are supposed to do when going into someone's room. She said it really upsets her when staff do not knock, especially when she is in the bathroom. During an interview with CNA D on 03/19/2025 at 1:11 p.m., she said that she had been trained on resident rights. She said the policy for knocking was that staff were supposed to knock, introduce themselves and let the resident know what you are there for. She said staff were to knock anytime they wanted to enter a resident's room. She said that staff were supposed to knock on the resident's bathroom door if the resident was in there. She also said that it was important to knock on the resident's door because it was their right to have privacy. She said if staff do not knock the resident may get startled. She said that nurses monitor to ensure staff are knocking on the resident's doors by observation. She said she did not realize she did not knock on Resident #81's and Resident #93's door. During an interview with RA C on 03/20/2025 at 11:51 a.m., she said that she had been trained on resident rights. She said that staff were supposed to knock on all residents' doors before entering. She also said that staff were supposed to introduce themselves and tell the resident what they were going to do. She said there was no reason staff should not knock on the resident's door before entering. She said by staff not knocking the resident may get angry. She said the nurses and management monitored to ensure staff were knocking on the residents doors. She said that the nurses and management would walk down the hall and remind staff to knock and do observations. She said that she thought she might have been nervous. During an interview with the ADM on 03/20/2025 at 11:29 a.m., she said that she and staff had been trained on resident rights and knocking on residents' doors. She said the policy was to knock on the door and inform the resident what they are there to do. She said all staff were supposed to knock before entering the resident's room. She said that it was important for staff to knock on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 2 of 24 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 03/20/2025 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident's door for their privacy. She said it was the resident's right. She also said that it was no different than someone coming to her house and not knocking. She said the resident had the right to be respected. She said the resident may feel like their rights are being invaded or the staff do not respect them. She said that all managers should be monitoring that staff are knocking on the door. She said management monitors it by observation. She said she did not know why staff were not knocking on resident's doors before entering. During an interview with the DON on 03/20/2025 at 4:53 p.m., she said she and staff had been trained on resident rights. She said the policy was that staff were to knock on the door no matter what you are going in there for except if it is an emergency such as the resident on the floor. She said it was important for staff to knock because it was the resident's right. She also said that the resident had the right to tell staff they did not want them in the room. She said that all management was responsible for monitoring to ensure staff are knocking. She said that management monitors it by going down the halls and reminding staff. She said she did not know why staff were not knocking on the residents' doors. She said it was not due to lack of education. Record Review of Quality of Care- Dignity Policy dated February 2020 revealed that staff are expected to knock and request permission before entering residents' rooms. Residents' private space and property are respected at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 3 of 24 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 03/20/2025 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 of 8 residents (Resident #95) reviewed for unnecessary drugs. Residents Affected - Few The facility failed to ensure Resident #95 had a duration for antibiotic therapy. This failure could place residents at risk of nausea, diarrhea, and multi-drug resistant organisms. Findings included: Record review of Resident #95's face sheet, dated 2/20/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #95's admission MDS, dated [DATE], revealed a BIMS score of 0, which indicated severe cognitive impairment. Section I-Active Diagnoses included personal history of urinary tract infections, cognitive communication deficit (difficulty communicating thoughts), and unspecified dementia (a disease process that affects thinking process and memory). Record review of Resident #95's Acute Care Plan Antibiotic, dated 02/17/2025, revealed under Problem/Need relate to a handwritten prophylactic (preventative) in the last blank provided, Resulting in with handwritten Amoxicillin 250mg QD open-ended, Target/Review date was left empty and Interventions with monitor vital sign freq. with handwritten Q 8 in the blank provided. No boxes were checked on the form. Record review of Resident #95's care plan, dated 02/20/2025, revealed [Resident #95] has history of urinary tract infection and is at risk for UTIs r/t incontinence, debility (physical weakness). Is on prophylactic [NAME]. Approach included administer antibiotics as ordered and observe for effectiveness/adverse side effects. Record review of Resident #95's physician order dated 02/1/2025 revealed Amoxicillin 250mg 1 po qd -UTI prophylaxis. Record review of Resident #95's physician notes written by the nephrologist (kidney specialist) dated 02/18/2025 revealed Patient is to take amoxicillin 250mg every day until further notice, if any questions please call my office. Record review of Resident #95's antibiotic surveillance form revealed Infection Category and other circled. The sections titled nosocomial (facility acquired) or community acquired and symptoms present were not completed. The section titled related dx revealed prophylactic. Under other interventions and precautions taken revealed Amoxicillin 250mg QD open-ended During an interview on 03/19/2025 at 02:15 PM with the ICPC, she stated she had been employed with the facility for 2 years. She stated that she had specialty training in infection prevention and control and was responsible for overseeing infection prevention and control. She stated that she expected all antibiotic orders to meet the criteria of McGeer (a tool designed to support facility healthcare-associated infection surveillance). The ICPC stated all antibiotic orders needed a diagnosis, and end date or duration, and have a 72 hour follow up. She stated if an order for antibiotics did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 4 of 24 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 03/20/2025 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few meet criteria, then she would contact the NP to discontinue the order, and if needed the MD would have been contacted related to the appropriateness of the antibiotic. The ICPC stated if a prophylactic antibiotic was written by a nephrologist , then she would not question the order. She stated she did not complete the McGeer's for prophylactic antibiotics. The ICPC stated a resident could become resistant to the antibiotic or have side effects like nausea and diarrhea if they were to take antibiotics for a long period of time or if it was not needed. During an interview on 03/19/2025 at 04:17 PM with the DON, she stated that doing a McGeer assessment was not required for prophylactic antibiotic orders. During an interview on 03/19/2025 at 05:03 PM with the DON, she stated that she was unaware that all prophylactic antibiotic orders required an end date or duration. Attempted interview on 03/20/2025 at 01:07 PM with MD, left voicemail and no return call received prior to exiting the facility. Attempted interview on 03/20/2025 at 01:15 PM with RPh, left voicemail and no return call received prior to exiting the facility. During an interview on 03/20/2025 at 01:35 PM with the NP, she stated that she does not prescribe any prophylactic antibiotic orders. She stated that she was aware of the prophylactic antibiotic order for Resident #95, but the nephrologist wrote the order. The NP stated the resident could develop antibiotic resistance if on antibiotics for extended periods of time. During an interview on 03/20/2025 at 04:10 PM with LVN F, he stated he had been employed with the facility for about 8 months. LVN F stated if he received a new order for antibiotics, he was expected to check for a duration/end date. He stated if there was not an end date then he was expected to contact the provider for clarification. He stated any prophylactic antibiotic orders required notification of the responsible party and a care plan. He stated they monitored for side effects of the antibiotics like nausea, diarrhea, and rash. LVN F stated over time residents could become resistant to the antibiotics. He stated if the doctor and family know it is all right. I mean they have the right to prescribe the medication. During an interview on 03/20/2025 at 04:40 PM with LVN G, she stated she had worked at the facility for 10 years. She stated that a diagnosis and duration are required on all antibiotic orders. She stated if something were missing from the order, she would have contacted the provider for clarification. LVN G stated all nursing staff were responsible for ensuring antibiotics were being prescribed appropriately because residents could develop side effects like rash, hives, diarrhea, or resistance to antibiotics. During an interview on 03/20/2025 at 05:08 PM with the DON, she stated she expected nurses to ensure new orders for antibiotics included a diagnosis and a stop date. She stated if any component of the order was missing, then she expected the nurse to contact the provider for clarification. The DON stated it was her and the ICPC's responsibility to ensure antibiotics were appropriate and follow up cultures or labs were ordered. She stated if there was any question about the order then it was her or the ICPC's responsibility to contact the provider to obtain clarification. She stated she could question an order for antibiotics, but the provider did not always change the order. She stated she did not always find prophylactic antibiotics to be helpful, but she was not a provider and she just wanted to follow best practices. The DON stated if a resident were on antibiotics long term or when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 5 of 24 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 03/20/2025 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 0757 not needed it could cause a multi-drug resistant organism. Level of Harm - Minimal harm or potential for actual harm During an interview on 03/20/2025 at 05:21 PM with the ADM, she stated her expectations for nurses when they received an order for antibiotics were to ensure there was a reason for taking the antibiotics. She stated she did not know why an antibiotic would be ordered if there was not a current infection. She stated she was aware of a prophylactic antibiotic order, but the order was prescribed by an outside doctor that was a specialist. She stated she believed there should have been an end date on all the antibiotic orders. The ADM stated she expected the DON and the ICPC to get with the NP or MD to figure out a plan if there was not a clear diagnosis and end date. The ADM stated the resident's immune system could get to where the antibiotic is not working for them anymore. Residents Affected - Few Record review of facility policy titled Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes, dated 2001 and revised in 12/2016, revealed. Policy Statement Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. Policy Interpretations and Implementation . 2. The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. a. Therapy may require further review and possible changes if. 1. The organism is not susceptible to antibiotic chosen. 2. The organism is susceptible to narrower spectrum antibiotic. 3. Therapy was ordered for prolonged surgical prophylaxis; or 4. Therapy was started awaiting culture, but culture results and clinical findings do no t indicate continued need for antibiotics . 4. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 6 of 24 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 03/20/2025 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 0757 All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include: Level of Harm - Minimal harm or potential for actual harm a. Residents Affected - Few Resident name and medical record number. b. Unit and room number. c. Date symptoms appeared. d. Name of antibiotic. e. Start date of antibiotic. f. Pathogen identified. g. Site of infection. h. Date of culture. i. Stop date. j. Total days of therapy. k. Outcome; and l. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 7 of 24 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 03/20/2025 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 0757 Adverse events. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 8 of 24 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 03/20/2025 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 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 observations, interviews, and record review the facility failed to ensure the facility established and maintained an infection prevention program designed to provide a safe environment and to help prevent the transmission of communicable diseases for 3 of 5 staff (LVN A, MA B and Certified Nurse Aide D ) observed for infection control Residents Affected - Some LVN A and MA B failed to disinfect the blood pressure cuff while using it on Residents #94, Residents #19 , Residents #39 , Residents #301. The facility failed to ensure Certified Nurse Aide D conducted hand hygiene in between feeding assistants of residents during dining. These failures could place residents at increased risk of healthcare associated infections. Findings included: 1. Review of Resident #19's Face Sheet reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Resident #19 had diagnoses of Heart failure, Repeated falls, Acute Respiratory Disease, Muscle wasting and Atrophy, Chronic pain syndrome, Vitamin D deficiency, Hypertension, Lack of coordination and Abnormalities of gait and Mobility. Review of Resident #19's quarterly MDS dated [DATE] reflected a BIMS score of 15 which indicated she was cognitively intact. Review of Resident #19's Care Plan dated 01/22/2025 reflected; Resident #19 with diagnosis of hypertension, potential for complications. The relevant intervention was observing for changes in condition that may warrant increased supervision/assistance and notify MD/NP as needed. Review of Resident #19's physician's order reflected : Metoprolol Tartrate tablet; 100 mg; amt: 1; oral. Special Instructions: Hold SBP less than 110, HR less than 60. Review of Resident #94's Face Sheet reflected she was an [AGE] year-old female admitted on [DATE]. Resident #94 had diagnoses of Shortness of breath, Allergy, Deficiency of other vitamins, Insomnia, Hypertension, Chronic obstructive pulmonary disease (condition with difficulty to breath), Constipation, Muscle weakness , History of falling and Nausea with vomiting. Review of Resident #94's initial MDS dated [DATE] reflected a BIMS score of 09 which indicated she had moderately impaired cognition. Review of Resident #94's Care Plan 02/19/2025 reflected; Resident #94 with CHF has the potential for elevated BP and at risk for exacerbation. The relevant intervention was observing for abnormal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 9 of 24 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 03/20/2025 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 0880 respirations/lung sounds and blood pressure. Level of Harm - Minimal harm or potential for actual harm Review of Resident #94's physician's order reflected : Amlodipine tablet; 10 mg; 1 TAB; oral .Special Instructions: Hold for SBP less than 110 or SBP less than 60. Residents Affected - Some Review of Resident #39's Face Sheet reflected she was an [AGE] year-old female admitted on [DATE]. Resident #39 had diagnoses of Constipation, Osteoporosis (weak and fragile bones) , Depressive disorders, History of falling, Muscle wasting, Muscle weakness , Generalized anxiety disorder, Hypertension, Chronic obstructive pulmonary disease (condition with breathing difficulty) and Allergy. Review of Resident #39's quarterly MDS dated [DATE] reflected a BIMS score of 13 which indicated she was cognitively intact. Review of Resident #39's undated Care Plan reflected; Resident #39 with hypertension and had the potential for change in blood pressure and fluid volume, dehydration, fluctuations in weight and complications related to the diagnosis. The relevant intervention was monitoring blood pressure, vital signs as per protocol /as ordered. Review of Resident #301's Face Sheet reflected she was an [AGE] year-old female admitted on [DATE]. Resident #301 had diagnoses of Alzheimer's disease, UTI, Chronic kidney disease, Hypertension, Constipation and Nausea with vomiting. Review of Resident #301's initial MDS dated [DATE] reflected a BIMS score of 02 which indicated she had severely impaired cognition. Review of Resident #301's Care Plan 01/22/2025 reflected; Resident #301 with hypertension and had the potential for change in blood pressure and complications related to the diagnosis. The relevant intervention was observing for signs and symptoms of elevated blood pressure. Review of Resident #301's physician's order reflected : Losartan tablet; 25 mg; amt: 1/2 tab (12.5 mg); oral. Special Instructions: hold for SBP<100, DBP<60, or HR<60. Observation on 03/18/25 beginning at 9:20 AM revealed MA B was administering medications to the residents in Hall 200. While taking blood pressure of Resident #19 and Resident #94, MA B had not sanitized the blood pressure cuff before Resident #19 , in between Resident #19 and Resident #94 and after checking blood pressure of Resident #94. During an interview on 03/18/25 at 10:10 AM MA B stated she did not sanitize the blood pressure cuff in between residents though she knew it was necessary . She stated she forgot to do so as she was nervous. She stated sanitizing the blood pressure cuff in between each resident was necessary to ensure infection control by reducing the risk of transferring the germs from one resident to another. MA B said she received on going in-services pertaining to infection, abuse and neglect and falls however could not recall any trainings provided specifically for sanitizing medical equipment, including blood pressure cuffs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 10 of 24 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 03/20/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 03/20/25 starting at 9:50 AM LVN A was administering medications to the residents in Hall 200. It was observed that LVN A, without sanitizing the wrist blood pressure monitor used it on Resident #39 and Resident#301. She took the blood pressure of Resident #39 without sanitizing the cuff and after the completion without sanitizing she used the same blood pressure cuff on Resident #301. After completing the process she kept it on the medication cart, completed administering medications to Resident #301 and then moved on to the next resident. In an interview on 03/20/25 at 10:20AM LVN A stated she administer medications to the residents when there was no MA s available. She stated the correct process of using blood pressure cuffs on residents was, wiping it down (sanitize) in between each resident to avoid passing germs. LVN A stated she forgot to sanitize the blood pressure cuffs. She stated she received in services on sanitizing blood pressure cuffs sometime in the past however unable to recollect the exact month as it was not recently. 2. Record review of Resident #27's Face Sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident's diagnoses include Dementia (symptoms affecting memory, thinking, and social abilities, which interfere with daily life), Cognitive Communication Deficit (problems with communication caused by impaired cognitive processes), Dysphagia (difficulty swallowing), Muscle Wasting and Atrophy (loss of muscle mass and strength), Age-related Osteoporosis (bone formation is not keeping up with bone removal), Chronic Kidney Disease (condition characterized by progressive damage and loss of function in the kidneys), and Gastro-Esophageal Reflux Disease (stomach acid repeatedly flows back up into the tube connecting the mouth and stomach). Record review of Resident #27's Care Plan, dated 03/05/2025, reflected resident had impaired cognitive function/dementia. The goal was for Resident #27 to maintain current level of cognitive functions. Interventions for Resident #27 included: resident will not have an allergic reaction to ingestion. Resident will not exhibit signs and symptoms of drug related: hypotension (low blood pressure), sedation (in a relaxed easy state), anticholinergic (substances or drugs that oppose or block the effects of acetylcholine,) or extrapyramidal (involved in coordinating movement and motor control) symptoms/behaviors as evidenced by decreased behaviors thru next review date. Will remain comfortable and have needs met as promptly as possible. Resident will not exhibit signs of activity intolerance (fatigue, shortness of breath, pallor or cyanosis, vertigo, and weakness). Resident will be nourished, hydrated, and will maintain within 5% loss/gain of current weight. Resident needs will be anticipated, and resident will receive assistance with assisted daily living. Resident will maintain memory/recall ability as evidenced by recalling staff names, stating he/she is in a nursing home, and recognizing staff faces. Record review of Resident #27's quarterly Minimum Data Set, dated [DATE], reflected a Brief Interview for Mental Status Score of 99, which indicated cognitive impairment. The Minimum Data Set also reflected Resident #27 was dependent with eating, oral hygiene, toileting hygiene, shower/bathe, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. Record review of Resident #75's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident's diagnoses include Degeneration of brain (progressive loss of structure or function of neurons), Ulcerative Blepharitis left eye (inflammation of the eyelid margins), Hypokalemia (lower-than-normal levels of potassium in the bloodstream), Muscle weakness (lack of muscle strength), Muscle wasting and Atrophy (loss of muscle mass and strength), Hypothyroidism (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 11 of 24 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 03/20/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm (underactive thyroid), Chronic Kidney Disease (gradual loss of kidney function), Dysphagia (difficulty swallowing), Edema (swelling caused by too much fluid trapped in the body's tissues), Pulmonary Hypertension (high blood pressure affects arteries of the lungs, and right side of the heart), and Hypothyroidism (abnormally low activity of the thyroid gland, resulting in slowing of growth metabolic changes in adults). Residents Affected - Some Record review of Resident #75's Care Plan, dated 01/08/2025, reflected resident has Dysphagia and Chronic Kidney Dieses. Resident #75's goal's are: for to have needs met with as little frustration or distress as possible. Resident will not have an allergic reaction to ingestion. Resident will verbalize relief of pain. Resident will be kept comfortable. Resident will be nourished, hydrated and will maintain within 5% loss/gain of current weight. Resident needs will be met. Record review of Resident #75's quarterly Minimum Data Set, dated [DATE], reflected a Brief Interview for Mental Status Score of 99, which indicated cognitive impairment. The Minimum Data Set also reflected Resident #75 was dependent with eating, oral hygiene, toileting hygiene, shower/bathe, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene as well as is not applicable to shower/bathe and personal hygiene. Observation on 03/18/2025 at 12:10 PM during dining services, Certified Nurse Aide E was providing Resident #27 and Resident #75 with feeding assistance at the same time in which it was observed Certified Nurse Aide E was not hand sanitizing in between touching residents, food, and utensils. Attempt interview on 03/20/2025 at 10:37 AM, with Resident #27 was conducted. It was confirmed Resident #27 is unable to answer questions and is nonverbal. Attempt interview on 03/20/2025 at 10:45 AM, with Certified Nurse Aide E in which it was advised by facility staff that Certified Nurse Aide E was not on duty nor will be in later to be available for conversation. Interview on 03/20/2025 at 11:15 AM, with Resident #75 conducted. Resident #75 stated her hands doesn't work well due to being over [AGE] years old. Resident stated staff help her with feeding, sometimes staff help with feeding another resident. Resident stated sometimes she see's staff wash hands and sanitize, but sometimes not. Resident stated hand washing and sanitization in between glove usage doesn't always happen or sometimes staff don't wear gloves during meal service. Resident stated when staff are feeding another resident, she doesn't know where the staff's hands could have been if the staff is not sanitizing them in between feeding or if staff gets up to go somewhere else and return without cleaning their hands. Resident stated she knows it can affect her, but she doesn't know exactly how with germs. Resident stated staff have to be careful, and she has to be careful of the staff if they aren't cleaning hands. Resident stated if staff don't sanitize their hands, it makes her feel like she doesn't want to eat. Resident stated she sees staff not following hand hygiene during feeding her, she keeps it to herself. Resident stated she doesn't remember which staff or who they are since she is older. Resident stated she doesn't know what the staff can be spreading from resident to resident or to her when feeding them and not sanitizing. Resident stated she feels that she's seen it multiple times but can't recall when it happens in the dining room. Resident stated she doesn't remember which staff members who help with feeding her or other residents she's seen it happen to and she can't remember the times it's happened since she's older, but she's seen the staff not sanitize or clean hands when feeding her. Attempt interview on 03/20/2025 at 11:55 AM, with two Family Representatives for Resident #27 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 12 of 24 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 03/20/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some conducted. I attempted to speak with Family Representatives via phone, there was no answer. Two call-out attempts were made for Family Representatives, a voicemail was left with a call back number. No return call was received. Interview on 03/20/2025 at 12:13 PM, with Certified Nurse Aide E via phone. Certified Nurse Aide E stated he doesn't speak English and only speaks Spanish in which he was priorly observed during dining services communicating with residents in English. I spoke to Certified Nurse Aide E in Spanish and attempted to speak with him in regard to Resident #27 and Resident #75. Certified Nurse Aide E stated that he is at work elsewhere and can't be on his phone and is unable to answer questions. When asked if there is a time he can speak, Certified Nurse Aide E stated that he is at work and has an appointment to get to in between which he can't speak to me. When asked what time he can speak after his shift, he didn't provide me a time. My contact number was provided in which no call back was returned. Interview on 03/20/2025 at 12:34 PM, with Certified Nurse Aide D was conducted. Certified Nurse Aide D stated the following: she has been trained in hand hygiene in which it went over, staff have to wash hands for 20 seconds and under fingernails. Not to contaminate from touching things and anything that would require providing resident care, hand sanitizing or washing, as well as sanitizing or washing hands in between gloves usage. Certified Nurse Aide D stated staff are to be sanitizing in between feeding more than one resident, or wash hands if they get up to do something and return back to feed residents. Certified Nurse Aide D stated staff not washing hands can affect residents if hand hygiene isn't being followed such as, passing germs, contamination, diseases, and potentially be fatal to some residents depending on their health conditions. Certified Nurse Aide D stated her expectations are for all staff to follow hand hygiene and enforce staff to keep practicing safe hand sanitization. Certified Nurse Aide D stated if staff don't follow hand hygiene when assisting two residents, like in this case it can affect Resident #75 since she has respiratory issues, and it can affect Resident #27 wellbeing since she has health issues as well. Certified Nurse Aide D stated it can affect resident's quality of life if staff are not properly following hand hygiene policies. Interview on 03/20/2025 at 4:50 PM, with Director of Nursing was conducted. Director of Nursing stated the following: she's been trained in hand washing and hand hygiene in which it went over all stated is what goes over. Director of Nursing stated she is in charge of making sure all staff are following hand hygiene, anytime she goes through the facility she reminds staff. Director of Nursing stated if staff don't follow hand hygiene policy, it can be an infection control issue and pass on pathogens to residents. Director of Nursing stated resident's quality of life can be affected if staff don't wash and or sanitize hands during feeding. Director of Nursing stated in regard to Resident #27 and Resident #75, it can affect them because their immune systems are compromised, and due to their older age, it can affect them and potentially be fatal. Director of Nursing stated her expectation for staff is to maintain hand hygiene and to follow the process they are taught. Director of Nursing stated the policy for hand sanitization is for staff to wash or sanitize before and after when assisting in between residents as well as between all food trays or assisting with feeding meals to resident in order to prevent contamination. Director of Nursing stated if staff are feeding more than one resident at a time, they must sanitize in between if their hands touch the resident or if they are cleaning the residents, including if staff come back to assist residents, staff must sanitize. The Director of Nursing stated staff are supposed to wipe blood pressure cuffs down with wipes in between each resident . She stated , skipping infection control protocols like hand hygiene, and sanitizing medical equipment could risk the spreading of contagious diseases through contamination. The Director of Nursing stated staff received in-services anytime they found any type of noncompliance in the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 13 of 24 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 03/20/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 03/20/2025 at 5:20 PM, with Administrator was conducted. Administrator stated the following: she has been trained in hand washing and hand hygiene in which it went over to make sure staff wash their hands for 20 seconds in the dining room and while providing resident care, use hand sanitizer in between passing trays, and including when feeding residents in between. Administrator stated the process of feeding multiple residents at once is that the staff member should not be touching each resident without hand sanitizing in between, if the staff member gets up and comes back, they should be washing their hands and or sanitizing. Administrator stated the last time hand hygiene and sanitization in-service was completed took place in the last two months to her knowledge. Administrator stated resident's quality of life can be affected in terms of infections especially if their immune system is low and staff pass something due to not following hand hygiene. Administrator stated Resident #27 and Resident #75 can be affected because they are older and have health issues. Administrator stated her expectations for staff are to follow hand hygiene and follow their training. Record review of in services since October ,2024 revealed an in-service conducted on hand sanitization on 11/13/2024 and no in-service provided on cleaning and disinfection of resident-care items and equipment . Review of facility Policy Cleaning and disinfection of resident-care items and equipment revised in October 2018 reflected: Policy Statement: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. Policy Interpretation and Implementation: . 1. (d). Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment) . 2. Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. Record review of the facility's Infection Control: Handwashing/Hand Hygiene Policy revised on August 2019 stated: this facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation. -Before moving from a contaminated body site to a clean body site during resident care; after contact with a resident's intact skin, after removing gloves, before and after eating or handling food, and before and after assisting a resident with meals. - All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. - All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. - Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 14 of 24 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 03/20/2025 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 0880 - Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: Level of Harm - Minimal harm or potential for actual harm - Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations. Residents Affected - Some - The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 15 of 24 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 03/20/2025 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to establish an infection and prevention and control program that included, at a minimum, an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 3 of 8 residents (Residents #48, #52, and #95) reviewed for antibiotic stewardship program. Residents Affected - Some The facility failed to follow the antibiotic stewardship policy for Residents #48, #52, and #95 by not ensuring an infection surveillance form was completed to ensure the appropriateness of the antibiotic per facility policy. This deficient practice could place residents at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased multi drug resistant organisms. Findings include: Record review of Resident #48's face sheet, dated 3/20/2025, revealed a [AGE] year-old female who was originally admitted to the facility on [DATE] and the most recent admission was 02/17/2025. Record review of Resident #48's readmission MDS, dated [DATE], revealed a BIMS score of 06, which indicated severe cognitive impairment. Section I-Active Diagnoses included acute kidney failure (the kidneys sudden inability to adequately filter waste), neurogenic bladder (lack of bladder control because of a nerve problem), non-Alzheimer's dementia (a progressive degeneration of memory, cognitive, and motor functions), and retention of urine. Record review of Resident #48's physician orders, dated 02/17/2025, revealed Cephalexin 500mg po BID for UTI x 5 days. Record review of Resident #48's infection surveillance form, dated 02/17/2025, revealed infection category with urinary circled. Nothing was circled under the category Nosocomial (facility acquired) or community acquired or symptoms present (check all that apply). After Related Dx: was UTI handwritten in the blank provided. After the section Other interventions and Precautions taken: was Cephalexin 500 mg BID x 5 days, handwritten in the blank provided. In the margin of the paper form, handwritten, was Returned from hospital with ABX. Record review of Resident #48's undated Acute Care Plan Antibiotic revealed Problem/Need relate to with a handwritten check next to UTI, Resulting in with handwritten Cephalexin 500mg BID x 5 days, Target/Review date with handwritten 1 week and Interventions with monitor vital sign freq. with handwritten Q8 in blank provided. The box next to UTI at the top of the form had a handwritten check. No check was indicated next to antibiotic therapy under resulting in. No check marks or handwritten comments were noted under strengths to draw on. No checkmarks or handwritten notes were under goal next to infection will resolve without complication. No checkmarks noted under interventions .nursing next to monitor vital signs Q8, give medication as ordered. Monitor for adverse/side effects., anticipate & provide PRN meds: cough, pain/discomfort, fever, anxiety, and no further interventions written in to blank space provided. No further interventions were written under Dietary, Social Services, or Activities. Record review of Resident #48's nurses progress notes titled Resident Acute Follow-up Documentation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 16 of 24 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 03/20/2025 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dated 02/17/2025-02/20/2025 revealed F/U readmit handwritten on form. A handwritten nurses' note was documented in boxes provided for every 8-hour shift with vital signs but no mention of antibiotics in any notes. Record review of Resident #48's progress note written by the NP, dated 02/17/2025, revealed Pt is seen today for readmission .Her initial urinalysis showed possible UTI, but urine culture showed mixed flora. She received 5 days of IV Rocephin for possible infection then transitioned to oral Keflex course .continue Keflex course. Record review of Resident #52's face sheet, dated 03/20/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Record review of Resident #52's quarterly MDS, dated [DATE], revealed a BIMS score of 13, which indicated no cognitive impairment. Section I-Active Diagnoses included quadriplegia (significant loss of motor function below the neck), Cerebrovascular Accident (damage to the brain when blood flow is stopped), hypertension (high blood pressure), and muscle wasting and atrophy (tingling, numbness or weakness in your arms and legs). Record review of Resident #52's physician orders, dated 02/18/2025, revealed Levaquin 500mg PO Daily x 7 days (Dx: acute URI). Record review of Resident #52's infection surveillance form, dated 02/18/2025, revealed infection category with respiratory circled. Nothing was circled under the category Nosocomial or community acquired or symptoms present (check all that apply). After Related Dx: was URI handwritten in the blank provided. After the section Other interventions and Precautions taken: was Levaquin 500mg x 7 days, handwritten in the blank provided. Record review of Resident #52's Acute Care Plan Antibiotic, dated 02/18/2025, revealed Problem/Need relate to with a handwritten check next to handwritten URI, Resulting in with handwritten Levaquin 500mg po QD x 7 days, Target/Review date with handwritten 1 week and Interventions with monitor vital sign freq. with handwritten Q8 in the blank provided. The box next to handwritten URI at the top of the form had a handwritten check. No check was indicated next to antibiotic therapy under resulting in. No check marks or handwritten comments were noted under strengths to draw on next to able to communicate needs or able to follow instructions. No checkmarks or handwritten notes were under goal next to infection will resolve without complication. No checkmarks noted under interventions .nursing next to monitor vital signs Q8, give medication as ordered. Monitor for adverse/side effects., anticipate & provide PRN meds: cough, pain/discomfort, fever, anxiety, and no further interventions written in to blank space provided. No further interventions were written under Dietary, Social Services, or Activities. Record review of Resident #52's nurses noted dated 02/18/2025-02/25/25 revealed a nurses note every shift with vital signs and no adverse reactions noted. Record review of Resident #52's progress note written by the NP, dated 02/18/2025, revealed Pt is seen today per nursing request. Nursing reports Pt c/o persistent cough and congestion .No acute fever, pain, SOB, wheezing, N/V/D, or AMS. He continues to have nasal congestion and reports having productive cough with greenish sputum(mucus that is coughed up). Will start pt on Levaquin 500mg PO daily x 7 days for treatment of acute URI . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 17 of 24 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 03/20/2025 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #52's physician orders, dated 03/04/2025, revealed Augmentin 875mg PO BID x 10 days (Dx: Acute bronchitis [an inflammation of the lining of the tubes that carry air to and from the lungs]). Record review of Resident #52's undated infection surveillance form revealed infection category with respiratory circled. Nothing was circled under the category Nosocomial or community acquired or symptoms present (check all that apply). After Related Dx: was Acute Bronchitis handwritten in the blank provided. After the section Other interventions and Precautions taken: was Augmentin 875mg po BID x 10 days, handwritten in the blank provided. Record review of Resident #52's undated Acute Care Plan Antibiotic revealed Problem/Need relate to with a handwritten check next to Acute Infection and a handwritten check next to handwritten Acute Bronchitis, Resulting in with handwritten Augmentin 875mg po BID x 10 days, Target/Review date with handwritten 2 weeks and Interventions with monitor vital sign freq. with handwritten Q8 in blank provided. The boxes next to Acute Infection and Acute Bronchitis at the top of the form had a handwritten check. No check was indicated next to antibiotic therapy under resulting in. No check marks or handwritten comments were noted under strengths to draw on next to able to communicate needs or able to follow instructions. No checkmarks or handwritten notes were under goal next to infection will resolve without complication. No checkmarks noted under interventions .nursing next to monitor vital signs Q8, give medication as ordered. Monitor for adverse/side effects., anticipate & provide PRN meds: cough, pain/discomfort, fever, anxiety, and no further interventions written in to blank space provided. No further interventions were written under Dietary, Social Services, or Activities. Record review of Resident #52's nurses' noted dated 03/04/2025-03/13/25 revealed a nurses note every shift with vital signs and no adverse reactions noted. Record review of Resident #52's progress note written by the NP, dated 03/04/2025, revealed Pt is seen today per Pt's request .He c/o still having persistent cough and chest congestion. He reports he is coughing up yellow/greenish sputum at times. No fever, HA, sore throat, chills, SOB, N/V/D, or other symptoms. There are rhonchi (abnormal lung sounds) to upper lobes of lungs . Record review of Resident #95's face sheet, dated 2/20/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #95's admission MDS, dated [DATE], revealed a BIMS score of 0, which indicated severe cognitive impairment. Section I-Active Diagnoses included personal history of urinary tract infections, cognitive communication deficit (difficulty communicating thoughts), and unspecified dementia (a disease process that affects thinking process and memory). Record review of Resident #95's physician order dated 02/17/2025 revealed Amoxicillin 250mg 1 po qd -UTI prophylaxis. Record review of Resident #95's infection surveillance form, dated 02/17/2025, revealed infection category with other circled. Nothing was circled under the category Nosocomial or community acquired or symptoms present (check all that apply). After Related Dx: was Prophylactic handwritten in the blank provided. After the section Other interventions and Precautions taken: was Amoxicillin 250mg QD open-ended, handwritten in the blank provided. Record review of Resident #95's Acute Care Plan Antibiotic, dated 02/17/2025, revealed under (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 18 of 24 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 03/20/2025 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Problem/Need relate to a handwritten prophylactic in the last blank provided, Resulting in with handwritten Amoxicillin 250mg QD open-ended, Target/Review date was left empty and Interventions with monitor vital sign freq. with handwritten Q8 in the blank provided. The box next to prophylactic at the top of the form was not marked. No check was indicated next to antibiotic therapy under resulting in. No check marks or handwritten comments were noted under strengths to draw on next to able to communicate needs or able to follow instructions. No checkmarks or handwritten notes were under goal next to infection will resolve without complication. No checkmarks noted under interventions .nursing next to monitor vital signs Q8, give medication as ordered. Monitor for adverse/side effects., anticipate & provide PRN meds: cough, pain/discomfort, fever, anxiety, and no further interventions written in to blank space provided. No further interventions were written under Dietary, Social Services, or Activities. Record review of Resident #95's care plan, dated 02/20/2025, revealed [Resident #95] has history of urinary tract infection and is at risk for UTIs r/t incontinence, debility(physical weakness). Is on prophylactic [NAME]. Approach included administer antibiotics as ordered and observe for effectiveness/adverse side effects. Record review of Resident #95's physician notes dated 02/18/2025 revealed Patient is to take amoxicillin 250mg every day until further notice, if any questions please call my office. During an interview on 03/19/2025 at 02:15 PM with the ICPC, she said she had been employed with the facility for 2 years. She stated that she had specialty training in infection prevention and control and was responsible for overseeing infection prevention and control. She stated that she utilized a mapping tool to monitor infections. She stated she was responsible for completing the infection surveillance form and care plan when a resident is started on antibiotics. The ICPC stated all antibiotic orders needed a diagnosis, and end date or duration, and have a 72 hour follow up. She stated if an order for antibiotics did not meet criteria, then she would contact the NP to discontinue the order, and if needed the MD would have been contacted related to the appropriateness of the antibiotic. The ICPC stated a resident could become resistant to the antibiotic or have side effects like nausea and diarrhea if they were to take antibiotics for a long period of time or if it was not needed. During an interview on 03/19/2025 at 04:17 PM with the DON, she stated that doing a McGeer assessment was not required for prophylactic antibiotics or antibiotic orders that were received with the discharge order from the hospital. Attempted interview on 03/20/2025 at 01:07 PM with MD, left voicemail and no return call received prior to exiting the facility. Attempted interview on 03/20/2025 at 01:15 PM with RPh, left voicemail and no return call received prior to exiting the facility. During an interview on 03/20/2025 at 01:35 PM with the NP, she stated that she does not prescribe any prophylactic antibiotic orders. She stated that she was aware of the prophylactic antibiotic order for Resident #95, but the nephrologist wrote the order. She stated that infections needed to meet criteria lined out on the infection surveillance form. The NP stated the resident could develop antibiotic resistance if on antibiotics unnecessarily or for extended periods of time. During an interview on 03/20/2025 at 04:10 PM with LVN F, he stated he had been employed with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 19 of 24 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 03/20/2025 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 0881 Level of Harm - Minimal harm or potential for actual harm facility for about 8 months. LVN F stated if he received a new order for antibiotics, he was expected to check for all components of the orders, then administer the medication within 4 hours. He stated all residents needed to be monitored for side effects of the antibiotics like nausea, diarrhea, and rash and their vital signs for the duration of antibiotic therapy and 72 hours afterwards. LVN F stated over time residents could become resistant to the antibiotics. Residents Affected - Some During an interview on 03/20/2025 at 04:40 PM with LVN G, she stated she had worked at the facility for 10 years. She stated all antibiotic orders must have the resident's name, name of the medication, dosage, frequency, duration, diagnosis, and route. She stated if something were missing from the order, she would have contacted the provider for clarification. LVN G stated all nursing staff were responsible for ensuring antibiotics were being prescribed appropriately because residents could develop side effects like rash, hives, diarrhea, or resistance to antibiotics. During an interview on 03/20/2025 at 05:08 PM with the DON, she stated she expected nurses to ensure new orders for antibiotics included all necessary components. She stated if any component of the order was missing, then she expected the nurse to contact the provider for clarification. The DON stated it was her and the ICPC's responsibility to ensure antibiotics were appropriate by using the surveillance form and to follow up on cultures or labs were needed or ordered. She stated if a resident was admitted from the hospital, they did not always get the labs and cultures, so the surveillance was not done. She stated if there was any question about the order then it was her or the ICPC's responsibility to contact the provider to obtain clarification. She stated she could question an order for antibiotics, but the provider did not always change the order. The DON stated if a resident were on antibiotics long term or when not needed it could cause a multi-drug resistant organism. During an interview on 03/20/2025 at 05:21 PM with the ADM, she stated her expectations for nurses when they received an order for antibiotics were to ensure there was a reason for taking the antibiotics. She stated she expected the IPCP or the DON to complete the infection surveillance form anytime an antibiotic was prescribed. She stated she was unaware of any situation that a surveillance form would not have been completed with a new antibiotic order. The ADM stated the resident's immune system could get to where the antibiotic is not working for them anymore or the antibiotic could make them sick. Record review of facility policy titled Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes, dated 2001 and revised in 12/2016, revealed. Policy Statement Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. Policy Interpretations and Implementation 1. As part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist, or designee. 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 20 of 24 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 03/20/2025 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 0881 The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. Level of Harm - Minimal harm or potential for actual harm a. Residents Affected - Some Therapy may require further review and possible changes if. 1) The organism is not susceptible to antibiotic chosen. 2) The organism is susceptible to narrower spectrum antibiotic. 3) Therapy was ordered for prolonged surgical prophylaxis; or 4) Therapy was started awaiting culture, but culture results and clinical findings do no indicate continued need for antibiotics . 4. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include: a. Resident name and medical record number. b. Unit and room number. c. Date symptoms appeared. d. Name of antibiotic. e. Start date of antibiotic. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 21 of 24 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 03/20/2025 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 0881 f. Level of Harm - Minimal harm or potential for actual harm Pathogen identified. g. Residents Affected - Some Site of infection. h. Date of culture. i. Stop date. j. Total days of therapy. k. Outcome; and l. Adverse events. Record review of facility policy titled Infection Prevention and Control Program, dated 2001 and revised 8/2016 revealed. Policy Statement 1. The infection prevention and control program are a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. 2. The element of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. Policy Interpretation and Implementation . . 3. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 22 of 24 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 03/20/2025 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 0881 Surveillance Level of Harm - Minimal harm or potential for actual harm a. Residents Affected - Some Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency detecting outbreaks and epidemics, monitoring employee infections, and detecting unusual pathogens wit infection control implications. c. Standard criteria are used to distinguish community-acquired from facility-acquired infections. 4. Antibiotic Stewardship a. Culture reports, sensitivity data, and antibiotic usage reviews are included in surveillance activities. b. Medical criteria and standardized definitions are used to help recognize and manage infections. c. Antibiotic usage is evaluated, and practitioners are provided feedback on reviews . Record review of facility policy titled Surveillance for Infections, dated 2001 and revised 09/2017, revealed. Policy Statement The Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. Policy Interpretations and Implementation 1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated Infections, to guide appropriate interventions, and to prevent future infections. 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 23 of 24 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 03/20/2025 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 0881 The criteria for such infections are based on the current standard definitions of infections . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675914 If continuation sheet Page 24 of 24