Health inspection·July 26, 2024

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An observation of another video clip on [DATE] at 11:00AM revealed, CNA B had not changed her gloves at any point of time during the peri care on Resident #1. She entered Resident#1's room and donned a pair of gloves without washing her hands, then removed the soiled brief and wiped her perineal area and bottom. After the completion she open the cupboard and picked up a new brief with the soiled gloves and applied it on Resident #2. CNA B handled the packet containing wet wipes with same pair of gloves and stored it away in the cupboard. She then adjusted the side table and covered Resident #1 with blanket. After that, she brought a drinking beaker holding with the contaminated gloves, recapped it and arranged on the side table for Resident #1. During an interview on [DATE] at 10:00AM the FM stated the family installed a camera in Resident #1's room so that the family could closely monitor the activities in her room. She stated the video involving CNA A was recorded on [DATE] at 7:22AM and the video with CNA B was recorded on [DATE] at 7:00AM. FM stated she was devastated with the incompetency of the staff at the facility. During an interview on [DATE] at 1:30PM., CNA A stated she was in a hurry and breached the infection control protocols. She stated by doing that she contaminated everywhere by touching with soiled gloves. She continued, mistakes could happen with anyone and the best way to resolve it was learning from the mistakes. CNA A stated following infection control protocol was important to minimize spreading diseases from one resident to another. CNA A stated she received trainings on infection control last month. During an interview on [DATE] at 2:30PM., CNA B stated she started working at the facility since [DATE]. CNA B said she was not aware that she was doing anything wrong at that time. When watched the video she realized she was spreading germs all over the place by handling things with dirty gloves. She said it was important to follow infection control policies to minimize the risk of contagious diseases. She said she received in services on infection control however unable to say exactly when the training was. Review of Resident #2's face sheet, dated [DATE], reflected Resident #2 admitted to the facility on [DATE]. She was a [AGE] year-old female diagnosed with Hypertension, Hyperlipidemia, Osteoarthritis, Pain, Muscle spasm, Iron deficiency, Anemia, Hypothyroidism, Vitamin D deficiency, Age-related cognitive decline, Cough, Insomnia and Diarrhea, Record review of Resident #2's MDS assessment dated [DATE], reflected her BIMS was 07 indicating severe cognitive impairment. Record review of Resident #2's care plan dated [DATE] reflected, she was incontinent with uninhibited bowel and bladder. Potential for UTI. Potential for constipation and the relevant intervention was Provide incontinent care promptly when found wet or soiled. During an observation on [DATE] at 11:30 AM. revealed, CNA C at the beginning of peri care did not wash or sanitize her hands, also did not change the dirty gloves before handling new brief on Resident #2. CNA C donned the gloves, removed the soiled brief and wiped the front and bottom of Resident #2. CNA C then picked up a new brief with the soiled gloves and applied it on Resident#2. CNA C changed her dirty gloves after that and completed the resident care. During an interview on [DATE] at 12:00PM., CNA C stated she was nervous and forgot to follow the correct steps in doing peri care. She stated she should have washed her hands and changed gloves whenever handling new items, after handling dirty items. CNA C stated she was risking the spread of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675918 If continuation sheet Page 2 of 4 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 675918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gracy Woods Nursing Center 12021 Metric Blvd 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 illnesses through contamination by not following infection control protocols. CNA C stated she had numerous infection control in services, almost every month. During an interview on [DATE] at 3:30 p.m., DON stated she saw both the videos and breaching of infection control by CNA A and CNA B was not acceptable, as it was evident in the video. The DON stated the facility policy provide very clear guideline about the importance of following infection control protocol. The DON said CNA A, CNA B and CNA C needed one to one education as they had very limited understanding about infection control practices. She stated her expectation was, the nursing staff follow the facility policy/procedure for handwashing / sanitization during and after peri care and also changing the gloves at the required time as suggested in the facility policy. DON added, this was essential to stop spreading transmittable diseases. Review of the in-service records from [DATE] to [DATE] reflected there were no in services conducted on peri care. Review of facility's policy titled standard precautions revised in [DATE] reflected: Standard Precautions are used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. Standard Precautions apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases 1. Hand hygiene Hand hygiene is performed with ABHR or soap and water: Before and after contact with the resident. After direct or indirect contact with dirt, blood, or body fluids After removing gloves . 2. Gloves Gloves (clean, non-sterile) are worn when in direct contact with blood, body fluids, mucous membranes, non-intact skin, and other potentially infected material . e. Gloves are changed as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675918 If continuation sheet Page 3 of 4 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 675918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gracy Woods Nursing Center 12021 Metric Blvd 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 g. Gloves are removed promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident. h. After gloves arc removed, wash hands immediately to avoid transfer of microorganisms to other residents or environments . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675918 If continuation sheet Page 4 of 4