Health inspection·July 31, 2025

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some staff. He stated he used a paper dictionary for translating some requests from Russian to English and writing them down. He revealed he asked to get his morning medication with food and med aides continue bring his morning medication before breakfast and he does not want to take medications on the empty stomach. He stated he was satisfied with nursing care in this facility: he gets his showers and food on time, and he liked it here, but he cannot participate in activities as nobody understands him. Resident #73 stated he participated in therapy where he received a printout with pictures/words in Russian/English. The social worker uses the Google translator with him and was trying to assist him with getting an iPad or new phone for using a google translator. He stated he was estranged from his family and only has one friend who visited him here and he can communicate his needs through her sometimes. He wanted to see a cardiologist for his cardiac conditions. The resident #73 provided the surveyor with written notes of his situation before and after admission to this facility with request to address the lack of communication available for him here at the facility. In an Interview on 07/30/2025 at 8:29 a.m., resident reported he was “frustrated” because staff fail to attempt to communicate with him and they do not understand his needs. Interview of LVN B on 7/30/25 at 11:47 a.m., revealed she provided speech therapy services to Resident #73 who stated she worked on improving problem solving to facilitate decision making skills for care/need using Google translator on her phone and her responded well to communication with use of electronic translator. Resident does not have any speech impairment and improved in swallowing food with being discharged on 7/11/25 from Speech therapy. Resident voiced his concern of not being able to communicate to nursing staff regarding his needs. She assisted him on communicating the need for itching medication to the nurse once. Speech therapist stated that not being able to communicate to nursing staff can cause medical decline and depression in this resident. Interview with the DOR on 7/30/25 at 10:45 a.m., revealed Resident #73 was seen by PT, OT, and Speech therapy from 6/17-7/11/25 for improving independence with ADLs. This resident participated well in therapy during this period. There was not a goal for improving functional communication with staff members in this facility for him, but he was provided with communication paper printouts of 10-20 words with Russian-English translation which he was able to utilize by pointing at words with pictures. The DOR stated Resident #73 was able to understand the therapy instructions with use of Google translator during therapy sessions. She stated the resident was physically independent with ADL tasks and able to communicate but needs a way to translate his needs from Russian to English. She was not aware of his frustration regarding inability of communicating his needs to nursing staff. She participated in staff meetings and was not aware it was an issue with this resident. Interview on 07/30/2025 at 2:55 p.m., CNA A on hall 300 revealed he provided Resident #73 with ADL assistance using gestures and not through verbal communication due to the resident's inability to communicate in English and never used Google translator with this resident. CNA A stated Resident #73 received all needed ADL care on the regular basis and seemed happy, but he does not know how other nursing staff communicate to this resident. CNA A stated if the resident were not able to commutate his needs with gestures and staff does not understand him, it could compromise his care. Interview with CMA C, on 7/31/2025 at 1:45 p.m., stated she administered medications to the Resident #73, but she does not use Google translator with him. She stated the resident can write in English and using gestures to communicate to staff. She was not aware about him not wanting medications before breakfast. She stated he usually took medications in front of her, and she does not leave medications at his bedside. She asked the surveyor to show how to use a Google translator stating she heard from DON that she needed to use it but does not know how to do it. CMA C stated she does not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675918 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 675918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some remember having an in service for using the Google translator with this resident CMA C was aware of potential negative consequences on resident's health status due to lack of communication with staff. Interview with LVN A on 07/31/2025 at 5:05 p.m., revealed she provided Resident #73 with ADL care. LVN A stated Resident uses hand gestures or he wrote in English to explain his needs. LVN A stated they communicate with Resident #73 by writing my questions out and then allowing Resident #73 to write his responses. LVN A stated she has started using a translation app to communicate with Resident #73. Interview with the AD on 07/30/2025 at 12:38 p.m., revealed the AD offered options for activities to Resident #73 include listening to music and watching movies in his room. The AD stated she tried to get Resident #73 to join in the community activities however, Resident #73 has declines repeatedly. Interview with the SW on 07/30/2025 at 10:16 a.m., revealed he was looking into training for the care staff to use a translator application on their cell phones to communicate with non- English-speaking residents. The SW stated they often have residents who do not speak English and some of our Staff do not speak English. Therefore, the translation application was a useful resource to solve the communication problem. The SW stated Resident #73 might feel lonely if he was not understood by staff and his needs may not be getting met. Interview with DON on 07/31/2025 at 4:30 p.m., revealed care should include speaking and communicating with each resident. The DON explained the resident has a right to be communicated with regarding aspects of his care and daily living. The DON stated the staff have now been in-serviced on communication with non- English-speaking residents. The DON stated, Social Worker communicated with her regarding setting up training for staff of how to use the Google translation application. Interview with Administrator on 7/31/2025 at 5:00 p.m., revealed the staff will receive in- service training by Senior staff on methods for communication with non- English-speaking Residents. Administrator explained the DON and Social Worker will be providing in- service training. Resident #47 Record review of Resident #47's Face Sheet dated 02/28/2025 revealed Resident #47 was admitted to the facility on [DATE] and was a [AGE] year-old male with diagnoses: Fracture of lateral malleolus or right fibula, Intracardiac thrombosis, Inguinal hernia, open wound, right foot, initial encounter, abrasion, right hip, hypertension, pain. Review of Resident #47's Quarterly MDS, dated [DATE] reflected the following: Section GG Functional Abilities, the resident was “Independent” for ADLs meaning, Resident completes the activity by themself with no assistance from a helper. Section C, (BIMS) Brief Interview for Mental Status is scored of 06 (indicates moderate cognitive functioning). Review of Resident #47's Comprehensive Care Plan dated 07/02/2025 reflected that Staff needs to assess and ensure adequate access to call bell, light, and personal items on the open side. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675918 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 675918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 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 0558 Level of Harm - Minimal harm or potential for actual harm Interview Resident # 47 on 07/29/2025 at 10:41 a.m., Resident #47 stated he eats in the dining room, receives medications from the staff nurses and facility assist him with bathing. Resident #47 stated, “he wants Bengay for his pain.” Resident #47 stated “call button was not hooked up”. Surveyor observed call light button at the top of Residents #47's headboard not within reach of Resident #47. Residents Affected - Some Interview with Resident #47 on 07/31/2025 at 11:55 a.m., revealed Resident #47 had pain in both knees, feet, and shoulders. Resident #47 stated “I did not report my pain to the nurses when they came in my room to check on me because I forgot. Resident stated, “call button is not hooked up.” Observation on 07/31/2025 at 2:05 p.m., call light button was located on left side of bed, on the floor, under the bedside table and curled under a blue medical boot, trash can was in front of it. Call button was not within reach of resident. Interview on 07/31/2025 at 2:10 p.m., CNA C stated CNAs are responsible for the call button and she usually moved the call button closer to Resident #47. CNA C stated she will check on Resident # 47's call button location now. Interview on 07/31/2025 at 4:13 p.m., CNA D stated Resident #47 may not get the care he needs if he cannot reach the call light button, and a resident could be negatively affected if the resident did not have access to the call light. Record Review of Translation and/or Interpretation of Facility Services Policy dated May 2017 reveal the following information: “This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. It is understood that providing meaningful access to services provided by this facility requires also that the LEP resident's needs and questions are accurately communicated to the staff. Oral interpretation services therefore include interpretation from the LEP resident's primary language back to English. It is understood that to provide meaningful access to services provided by this facility, translation and/ or interpretation must be provided in a way that is culturally relevant and appropriate to the LEP individual.” FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675918 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 675918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 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 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 interview and record review, the facility failed to establish and maintain a homelike environment for 2 or 3 residents (Resident #87 and Resident #14) observed for environmental conditions. The facility failed to ensure Resident #87's and Resident #14's bedroom walls were upkept and homelike. This failure could cause residents psychological distress or feel uncomfortable. Based on interview and record review, the facility failed to establish and maintain a homelike environment for 2 or 3 residents (Resident #87 and Resident #14) observed for environmental conditions. The facility failed to ensure Resident #87's and Resident #14's bedroom walls were upkept and homelike.This failure could cause residents psychological distress or feel uncomfortable.Findings Included:Resident #87Record Review of Resident #87's face sheet revealed was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #87 had a diagnosis of schizoaffective disorder (mental health condition that is marked by symptoms such as depression and mania), Muscle Weakness, Hyperlipidemia (abnormally elevated levels of fat in the blood) and Hypothyroidism (condition where the thyroid gland does not produce enough thyroid hormone). Record Review of Resident #14's MDS record indicated Resident #87 had a BIMS of 14 which implied the resident was cognitively intact. An observation on 07/29/2025 at 11:45AM in Resident #87's bedroom revealed the resident's wall was scratched and torn next to his head. An interview on 07/29/2025 at 11:45AM. Resident #87 stated the wall next to his head has been ripped and scratched up since he has arrived at the facility. He stated he did not do damage the wall. Resident #87 stated it bothered him that the wall was like that. He denied telling the facility about this problem.Resident #14Record Review of Resident #14's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #14 had a diagnosis of Paranoid Schizophrenia, Unspecified Convulsions (involuntary muscle contraction sand spasms) and Benign Prostatic Hyperplasia Without Lower Urinary Tract (non-cancerous enlargement of the prostate gland).Record Review of Resident #14's MDS record indicated Resident #14 had a BIMS of 8 which implied the resident had moderate impairment with his cognition. An observation on 07/29/2025 at 12:00PM in Resident #14's bedroom revealed the resident's wall was scratched and torn up next to his head. An interview on 07/31/2025 at 2:41PM Resident #14 stated the wall next to his head has been damaged since before he arrived at the facility. He stated his bedroom, or home would not look like this if he were at home. An interview was conducted on 07/31/2025 at 3:00PM with the Maintenance Manager (MM). The MM reported he had been employed at the facility for 6 months. MM stated the policy for ensuring a homelike environment was for staff to notify him of environmental concerns. The MM stated he was not aware of any bedroom issues on the 400 halls. The MM stated the expectation when the rooms conditions are not good was to fix it. The MM stated the condition of the walls could negatively impact a resident by the resident potentially not wanting to be in the room. The MM stated the process for completing conditions inside the facility was for him to check the maintenance log, and he would go down the line to fix them. If there is something tremendously horrible then he will have someone come in to help him.An interview was conducted on 07/31/2025 at 4:30PM the DON reported they have been employed at the facility since January 2024. The DON reported receiving trainings on resident rights. The DON stated the policy for homelike environment was that the facility should provide an environment life that was conducive, good looking and better than one can live and be comfortable in. The DON stated she was aware of complaints for had been complaints about the condition of the resident's rooms on 400 halls. The DON stated the expectation when room conditions are not good would to be work on it right away. The DON stated depending on what it the environmental (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675918 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 675918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete issue was, it could psychologically bother the residents and wish there were paint on the wall. An interview on 07/31/2025 at 5:15PM the ADM reported they have been employed at the facility since May 2024. The expectation for homelike environment was to try to meet the standard of a homelike environment. The ADM stated the residents are hard on the building and the facility try their best to keep up with it. The ADM stated multiple staff members in and out which could lead to scratches on the wall and try to keep up with those things as quickly and timely as they can. The ADM stated she was unaware of any complaints of issues on the 400 hall. The ADM stated the expectation when room conditions are not good are to have maintenance go and assess the room, depending on what it was they would rectify the situation, or they would meet back with her. The ADM stated a negative impact this could have on a resident could be that the resident could not be happy with their room. Record review of facility provided document labeled Quality of Life: Homelike Environment and dated May 2017 reflected the following:1. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:a. Clean, sanitary, and orderly environmentb. Comfortable yet adequate lightingc. Inviting colors and decord. Personalized furniture and room arrangementse. Clean bed and bath linens that are in good condition.f. Pleasant neutral scents Event ID: Facility ID: 675918 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 675918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 5 residents (Resident #44 and Resident #41 and #103 of 4 medication carts MC A reviewed for pharmaceutical services. 1. The facility failed to document controlled medications from the medication cart on the narcotic count sheets for Resident #44, Resident #41, and Resident #103. 2. The facility failed to remove a discontinued bottle of controlled medication from the medication cart for Resident #103. This failure could place residents at risk of medication errors and drug diversion.Findings include: Record review of Resident #44's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included displaced intertrochanteric fracture of right femur, muscle spasms, acute pain due to trauma, and osteoarthritis. Record review of Resident #44's Physician Active Orders dated [DATE] reflected she had an order for the medication, Tramadol 50mg 1 tablet by mouth three times per day for pain. An observation on [DATE] at 09:00 AM of medication cart on 200 Hall revealed CMA A did not fill out the drug administration record for Resident #44's narcotic medication log after she administered Resident #44's Tramadol 50mg 1 tablet mouth three times per day for pain. Record review of Resident #44's medication administration record for [DATE]-[DATE], indicated Resident #44 received Tramadol 50mg 1 tablet mouth three times per day for pain on [DATE]. Resident #41 Record review of Resident #41's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnosis of generalized anxiety disorder. Record review of Resident #41's Physician Active Orders dated [DATE] reflected she had an order for the medication, Clonazepam 0.5mg 1 tablet PO twice daily for generalized anxiety disorder. An observation on [DATE] at 09:00 AM of medication cart on 200 Hall revealed CMA A did not fill out the drug administration record for Resident #41's narcotic medication log when she administered Resident 41's Clonazepam 0.5mg 1 tablet (controlled medication used for panic and seizure disorders). Record review of Resident #41's medication administration record for [DATE]-[DATE], indicated Resident #41 received Clonazepam 0.5mg 1 tablet PO twice daily on [DATE]. Interview on [DATE] at 11:25 AM with CMA A stated she administered the medications to Resident #44, and Resident #41, but failed to document the administration of the medications on Resident #44, Resident #15, and Resident #41's narcotic records. CMA A revealed she was aware of the facility policy, and she should have signed out the narcotic medication immediately following administration of medication for each resident. An observation on [DATE] at 10:15 AM and record review of the medication cart reconciliation for 500 halls revealed a bottle of Lacosamide 10mg/ml solution for Resident #103 with completed count (0) on the controlled narcotic administration record on [DATE], but the bottle remained in the medication cart with a residual of approximately 5mL of Lacosamide left in the bottle. An interview on [DATE] at 10:15 AM with MA C who stated she counted the medication Lacosamide 10mg/ml solution for Resident #103 with completed count (0) on the controlled narcotic administration record on [DATE] but failed to remove the bottle with some residual of medication left in the bottle and take to DON for storage and further destruction. MA C stated she was aware of the facility policy for proper medication storage and prompt removal of discontinued or completed medications from the med cart, and she should have signed out the narcotic medication immediately following administration of medication for each resident. Interview on [DATE] at 5:15 PM with the DON who stated they go through the carts, and depending on the med aide and their administration, ensure the narcotic count was correct, and the DON and other people do oversight. Every (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675918 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 675918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete shift includes count. The DON stated the narcotic count should be updated/completed when a medication was given to a resident right after the medication was administered to the resident. The DON stated all staff who use the medication cart were responsible for ensuring expired/unused medications are removed from the medication cart. The DON stated she had a nurse assigned who checked the medication carts once per week, as the risk of giving expired meds would be high. She further stated staff removed discontinued and completed antibiotics and narcotics to her, she logged the medications and then destroyed them at least once per month with the Pharmacist. Interview on [DATE] at 6:22 PM with the ADMIN revealed the CMAs and nurses were supposed to sign for the narcotic after a triple check and reviewing the five rights of medication administration and complete the sign out after the resident is given the medication. The ADMIN further stated if the count were not correct it could result in a medication shortage, or the ordering process could be off schedule for the resident. Review of the facility policy and procedure for Medication Administration dated [DATE] reflected,4. Medications are administered in accordance with prescriber orders, including any required time frame.22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record:a. The date and time the medication was administered.g. The signature and title of the person administering the drug. Review of the policy and procedure of Storage of Medications dated [DATE], reflected,5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.9. Unlocked medication carts are not left unattended. Event ID: Facility ID: 675918 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 675918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews, and record reviews; the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to dispose of open stored perishable food products. 2. The facility failed to properly label and date food products in the walk-in refrigerator and walk in freezer. 3. The facility failed to ensure Dietary Manager wore a facial hair restraint while performing duties throughout the kitchen. These failures could place residents who were served from the kitchen at risk for consuming contaminated food and developing foodborne illnesses.Findings included: Observation on 07/29/2025 at 8:15 AM revealed the Dietary Manager had a mustache in which was not covered with a facial hair restraint while he was performing duties in the kitchen area. Observation revealed Dietary Manager was not wearing a facial hair restraint while walking throughout the main kitchen area, food preparation area, and the walk-in refrigerator. Observation revealed the Dietary Manager did not put on a facial hair restraint during the entire time visiting in the kitchen conducting a walk-through. Observation on 07/29/2025 at 8:20 AM during a walk-through of the facility kitchen revealed the following:walk-in refrigerator*Open undated garlic,*Open undated white cheddar cheese,*Undated yellow cheddar cheese,*Open undated parmesan cheese,*Open undated cranberry juice,*Open undated deli ham,*Open undated sliced carrots, and*Open undated tortillas. walk-in freezer*Open undated frozen hamburger patties,*Open undated frozen broccoli,*Open undated frozen cheese pizzas,*Open undated frozen okra,*Open undated frozen mixed vegetables, and*Open undated frozen biscuit dough. Observation on 07/29/2025 at 12:00 PM revealed the Dietary Manager did not have his mustache covered while performing duties in the kitchen area. Observation revealed Dietary Manager was not wearing a facial hair restraint while walking throughout the main kitchen area, and food preparation area. Observation revealed Dietary Manager presented extra facial hair restraints to confirm there were facial hair restraints in supply and Dietary Manager did not put a facial hair restraint to cover his mustache once having facial hair restraints in his hands. Observation revealed Dietary Manager continued to perform duties in the kitchen area without utilizing a facial hair restraint. Observation revealed the Dietary Manager never put on a facial hair restraint, Observation on 07/30/2025 at 11:34 AM revealed the Dietary Manager scooped gravy into a cup assisting kitchen [NAME] in which Dietary Manager was not wearing a facial hair restraint to cover his mustache. Observation revealed Dietary Manager flipped chicken fried steak in a deep fryer while not wearing a facial hair restraint. Observation revealed Dietary Manager was checking food in the hot table station while not wearing a facial hair restraint. Observation revealed Dietary Manager walking through out the kitchen area performing duties without having a facial hair restraint on. Observation revealed Dietary Manager was checking food temperature without wearing facial hair restraint. Observation revealed the Dietary Manager never put on a facial hair restraint; Observation revealed Dietary Manager was checking food temperature without wearing facial hair restraint. Observation revealed Dietary Manager never put on and wore a facial hair restraint while conducting duties in the kitchen and working around food. During an interview on 07/30/2025 at 11:58 AM with [NAME] A, she stated she has been working at the facility for 3 years. [NAME] A stated she has been trained in wearing facial and hair restraints. [NAME] A stated it is important to wear facial and hair restraints to prevent hair going in the food and contaminating it. [NAME] A stated it is important because if there was hair in the food, a resident can feel upset from it and think the facility staff do not care about their well-being. [NAME] A stated all staff in the facility when entering the kitchen area have been trained to wear facial and hair restraints. [NAME] A stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675918 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 675918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many expectation was for all staff to wear facial and hair restraints no matter who the staff member was, if a staff member was seen without facial and hair restraints, the facility staff tell the individual to put on facial and hair restraints when working in the kitchen. [NAME] A did not provide a comment as to why the Dietary Manager was not utilizing a facial hair restraint for his mustache when he was in the kitchen area working but stated was the responsibility of all staff to always wear facial and hair restraints every day. [NAME] A stated has been trained in labeling and dating food products. [NAME] A stated the training went over labeling and dating food products or anything that has been opened needs to be labeled and dated, if it is open that day then staff are to label and date it. [NAME] A stated all food products need to be shut and secured properly. [NAME] A stated if there is any food not labeled or dated in the dry food storage, walk in refrigerator, and walk in freezer, it can get bacteria and get residents sick if consumed. [NAME] A stated all food not labeled and dated needs to be thrown away since staff will not know how long it has been stored. [NAME] A stated its import to label and date food products to make sure it is safe to consume for the residents. [NAME] A stated food exposed and not secured properly is a health contamination issue and cause foodborne illnesses. [NAME] A stated it will be an issue giving residents exposed open food or undated and unlabeled food, as it can make a resident ill or hospitalize the resident, and or potentially leading to a resident dying if they have a specific health issue. [NAME] A stated facility staff in the kitchen not labeling and dating food products poses a concern on the resident's quality of life. During an interview on 07/30/2025 at 12:12 PM with [NAME] B, he has been working at the facility for a little over a year. [NAME] B stated he has been trained in utilizing facial and hair restraints. [NAME] B stated the facility staff must wear facial and hair restraints to prevent food getting contaminated by any hair falling in during the preparation process. [NAME] B stated it was important to wear facial and hair restraints to prevent a resident having hair in the food and a resident can choke on the hair or get sick. [NAME] B stated some negative affects if facility staff are not wearing proper facial and hair restraints is a resident can get a foodborne illness. [NAME] B stated all staff in the facility have been trained to wear facial and hair restraints if they have facial hair or hair in general. [NAME] B stated the expectation is for all staff to wear facial and hair restraints while following the rules the facility has put in policy. [NAME] B stated it was the responsibility of the staff member and the Dietary Manager to make sure all staff are wearing facial and hair restraints as well as make sure there is always appropriate supplies. [NAME] B stated if he must wear facial hair restraint to cover his facial hair then anyone that comes into the kitchen must wear one. [NAME] B stated all staff in the kitchen are to wear facial and hair restraints at all times [NAME] B stated staff not wearing hair or facial hair restraints can cause a quality-of-life issue with residents because they would not want to eat food with hair in it and make residents think staff do not know what they are doing in the kitchen. [NAME] B stated he has been trained in labeling and dating food products. [NAME] B stated the training went over labeling and dating food products or anything that has been opened needs to be labeled and dated, to make sure the product is labeled the correct food item. [NAME] B stated all food products need to be shut and secured properly by the facility staff due to bacteria can grow and food can get spoiled or rotten effecting the other foods surrounding it. [NAME] B stated if there is any food not labeled or dated in the dry food storage, walk in refrigerator, and walk in freezer, it needs to be thrown away if they aren't able to get an exact date and timeframe it was opened to determine if the food product is still good to be given to residents. [NAME] B stated its import to label and date food products to make sure it is safe to consume for the residents and not run into the issue of not knowing when the food is potentially expiring. [NAME] B (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675918 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 675918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many stated food exposed and not secured properly is a health contamination and consumption issue, overall, it is a health hazard since facility staff will not know if the food has been affected by bacteria and potential foodborne pathogens. [NAME] B stated facility staff cannot be too cautious when dealing with elderly populations and individuals who may be vulnerable that the facility is serving. [NAME] B stated it will be an issue giving residents exposed open food or undated and unlabeled food, as it can get a resident ill or hospitalize the resident depending on the contaminated food product and the resident's health. [NAME] B stated not labeling and dating food products poses a concern on the resident's quality of life if they eat food that may potentially get them sick. During an interview on 07/30/2025 at 12:35 PM with Dietary Manager, he stated he has been working here for 3 years and has 45 years of experience working with residents in the nursing home population. Dietary Manager stated he has been trained in facial and hair restraints. Dietary Manager stated it is important to wear facial and hair restraints to prevent hair falling into food when prepping, cooking, and while in the kitchen performing duties. Dietary Manager stated he is not sure if the facility has a facial and hair restraint policy that stated any form of statement that facility staff need to wear facial hair restraints, he stated that he pleads the fifth (Pleading the fifth refers to invoking the Fifth Amendment right against self-incrimination in the United States) about not answering if he wears a facial hair restraint or not. Dietary Manager stated some negative affects if facility staff are not wearing proper facial and hair restraints is that a resident can potentially get sick if hair is in the food. Dietary Manager stated facial and hair restraints is to prevent food contamination and all staff are to wear them while in the kitchen. Dietary Manager stated he has beard guards, and it is appropriate for staff to wear a ball cap if there is a hair restraint along with it. Dietary Manager stated all staff in the facility are to wear facial and hair restraint and follow the rules of what the facility has trained staff. Dietary Manager stated all staff have been trained to wear facial and hair restraints and to follow it. Dietary Manager stated the expectation is for all staff to wear facial and hair restraints, all staff need to wear them when working with the population the facility serves. Dietary Manager stated it was the facility and responsibility of all staff that enter the kitchen to wear facial and hair restraints, staff make sure that is followed. Dietary Manager admitted he was not wearing a facial restraint to cover his mustache; he did not provide a statement as to why he was not wearing a facial hair restraint when asked about it. Dietary Manager stated he will be utilizing posted signs moving forward about facility staff wearing proper facial and hair restraints. Dietary Manager stated staff not wearing hair or facial hair restraints can cause a quality-of-life issue with residents if they find hair in their food. Dietary Manager stated he has been trained in labeling and dating food products. Dietary Manager stated he has a working kitchen and serving a purpose. Dietary Manager stated the training went over labeling and dating food products or anything that has been opened needs to be labeled and always dated. Dietary Manager stated all food products need to be shut and secured properly despite any food product it is, it should be tight and secured. Dietary Manager stated if there is any food not labeled or dated in the dry food storage, walk in refrigerator, and walk in freezer, it needs to be thrown away since staff will not know how long it has been stored. Dietary Manager stated any food not labeled or dated is not given to residents due to it being a hazard as well as lead to residents getting sick. Dietary Manager stated its import to label and date food products to make sure it is safe to consume for the residents. Dietary Manager stated food exposed and not secured properly is a health contamination issue and needs to be tossed out. Dietary Manager stated it will be an issue giving residents exposed open food or undated and unlabeled food, as it can get a resident ill or hospitalize the resident, and or potentially (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675918 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 675918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many leading to death if it affects the resident. Dietary Manager stated not labeling and dating food products poses a concern on the resident's quality of life and they are here to take care of the residents, not put them in danger. During an interview on 07/30/2025 at 1:05 PM with Dietitian, she stated she has been working at this facility for 9 years. Dietitian stated she has been trained in wearing facial and hair restraints. Dietitian stated it is important to wear facial and hair restraints as it is helping with food sanitation. Dietitian stated some negative affects if facility staff are not wearing proper facial and hair restraints is that staff's hair can fall into the resident's food and cause contamination. Dietitian stated the facial and hair restraints is used as a precaution barrier. Dietitian stated all staff in the facility have been trained to always wear facial and hair restraints when inside the kitchen area. Dietitian stated the expectation is for all staff to always wear facial and hair restraints with no exceptions. Dietitian stated if there is anyone not wearing facial and hair restraints in the facility kitchen, it is the facility staff responsibility to advise the individual in the kitchen who are not wearing restraints to do so. Dietitian stated she does not remember the last in-service that was conducted for facial and hair restraints. Dietitian stated it is the responsibility of all staff to wear facial and hair restraints. Dietitian stated wearing facial and hair restraints and following the policy is the kitchens precaution measures. Dietitian stated staff not wearing hair or facial hair restraints can cause a quality-of-life issue with residents such as if there is hair in the resident's food and the resident being upset by it. Dietitian stated she has been trained in labeling and dating food products in which there has been in-service for labeling and dating in the last few months. Dietitian stated the labeling and dating food products training went over anything that has been opened needs to be labeled and dated as well as any food products that come into the facility kitchen should always be labeled and dated. Dietitian stated all food products need to be shut and secured properly as well as covered as it is a food safety issue that can lead to food contamination. Dietitian stated it is her professional opinion if there is any food not labeled or undated in the dry food storage, refrigerator, and freezer, it needs to be thrown away and not given to residents to eat. Dietitian stated its import to label and date food products to make sure it is safe to consume for the residents. Dietitian stated any food exposed and not secured properly is a health contamination issue and should not be consumed as it would be questionable. Dietitian stated it will be an issue giving residents any exposed open food or undated and unlabeled food, as it can get a resident ill or potentially hospitalize the resident in some cases based on their vulnerability level. Dietitian stated not properly labeling and dating food products or providing unknown expired food poses a safety concern on the resident's quality of life. During an interview on 07/30/2025 at 2:42 PM with Director of Nursing, she stated she has been working at the facility for approximately 2 years. Director of Nursing stated she has been trained in facial and hair restraints in the kitchen area. Director of Nursing stated it is important to wear facial and hair restraints to prevent hair getting into food or utensils. Director of Nursing stated some negative affects if facility staff are not wearing proper facial and hair restraints is a resident can find hair in the food and mess with the resident psychologically. Director of Nursing stated all staff in the facility have been trained to wear facial and hair restraints while being in the kitchen. Director of Nursing stated the expectation is for all staff to wear facial and hair restraints when cooking and preparing food since it is a regulation that must be always abided by. Director of Nursing stated it is the responsibility of the Dietary Manager and all staff to wear facial and hair restraints in the kitchen, it is her expectation for the Dietary Manager to monitor it. Director of Nursing stated it is her expectation for all staff to undergo in-services for wearing facial and hair (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675918 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 675918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many restraints, in which she does not recall the last in-service. Director of Nursing stated staff not wearing hair or facial hair restraints can cause a quality-of-life issue with residents if they find hair in the food and may pose a hazardous issue for residents that have swallowing issue, and it will not be pleasant for the resident. Director of Nursing stated she has been trained in labeling and dating food products, but that is the kitchen staff and Dietary Managers responsibility. Director of Nursing stated the training went over dating food products for the resident and to not keep it for an extended period or expiring. Director of Nursing stated any food that has been opened is not labeled and dated; it needs to be thrown away. Director of Nursing stated all food needs to be shut and secured properly. Director of Nursing stated its import to label and date food products to make sure it is safe to consume for the residents and food does not last for an extended period in which it can pose a health concern if residents eat expired food that is not properly labeled and dated. Director of Nursing stated it will be an issue giving residents exposed open food or undated and unlabeled food, as it is a health concern. Director of Nursing stated not labeling and dating food can affect the resident's quality of life if they are eating food that has been potentially sitting for an extended period. During an interview on 07/30/2025 at 3:07 PM with Administrator, she stated she has been working at the facility for approximately over a year. Administrator stated she has been trained in facial and hair restraints. Administrator stated it is important to wear facial and hair restraints to prevent hair falling into the food and cause cross contamination. Administrator stated some negative affects if facility staff are not wearing proper facial and hair restraints is that a resident can find the food off putting when finding hair in the food. Administrator stated all staff in the facility have been trained to wear facial and hair restraints. Administrator stated she is unaware of any facial and hair restraints signs posted on the entrance or exit of the kitchen. Administrator stated the expectation is for all staff to wear facial and hair restraints if there is facial hair or hair on the individual. Administrator stated it is the responsibility of the Dietary Manager to make sure all staff are to wear facial and hair restraints. Administrator stated she does not recall the last facial and hair restraint in-service training. Administrator stated staff not wearing hair or facial hair restraints can cause a quality-of-life issue with residents as it is off putting in which the resident will not want to eat the food they are provided, and they would need to provide another food tray for the resident to eat. Administrator stated if the Dietary Manager were not wearing a facial hair restraint and she saw it, she would in-service him. Administrator stated when she has entered the kitchen, she has not seen a staff member not wearing a facial or hair restraint and if there were every any incidents, she would remind the staff. Administrator stated she has been trained in labeling and dating food products. Administrator stated the training went over labeling and dating food products or anything that has been opened needs to be labeled and dated as well as the facility staff will monitor for expiration dates. Administrator stated all food products need to be shut and secured properly. Administrator stated the Dietary Manager monitors to make sure all food is labeled and dated as well as to make sure all food products are secured properly. Administrator stated the Dietary Manager in-services the facility kitchen staff. Administrator stated if there is any food not labeled or dated in the dry food storage, walk in refrigerator, and walk in freezer, it needs to be thrown away since staff will not know the correct date and staff can't know for sure if the food is expired or not. Administrator stated its import to label and date food products to make sure it is safe to consume for the residents, so residents are served food that are not expired. Administrator stated she cannot comment on residents being served expired food being a health issues in terms of what can happen to them since she is not a nurse. Administrator stated food exposed and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675918 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 675918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete not secured properly is a health contamination issue as the food can become stale or lead to potential foodborne pathogens. Administrator stated it will be an issue giving residents exposed open food or undated and unlabeled food and paused stating that's a good question; and continued to state it can cause gastrointestinal distress issues for residents, it can get a resident ill, and or hospitalize residents who are more vulnerable than others. Administrator stated in terms of facility staff not labeling and dating food products posing a concern on the resident's quality of life, she states at this time it has not and she has not been reported that. Observation on 07/31/2025 at 11:09 AM during a walkthrough of the facility kitchen revealed the following:walk-in refrigerator* Open undated white cheddar cheese,*Open undated deli ham, and*Open undated tortillas. walk-in freezer*Open undated frozen mixed vegetables, and *Open undated frozen biscuit dough. Observation on 07/31/2025 at 11:13 AM revealed Dietary Manager did not have on a facial hair restraint to cover his mustache while being in the kitchen area. During an interview on 07/31/2025 at 11:20 AM with Dietary Manager, he did not state as to why he was not wearing a facial hair restraint to cover his mustache while being in the facility kitchen. Observation on 07/31/2025 at 1:28 PM revealed Dietary Manager did not have on a facial hair restraint to cover his mustache while being in the kitchen area. Observation revealed there were no posted signs stating that facility staff are required to wear facial hair and hair restraints before entering the kitchen. Observation revealed the Dietary Manager never put on a facial hair restraint during the entire 3-day survey when conducting at random observations. Record review of facility policy Food Safety and Sanitation dated 2021 reflected the following: All local, state, and federal standards and regulations will be followed to assure a safe and sanitary food and nutrition services department.1. Food and Nutrition Services Departmenta. The department will be routinely inspected by the environmental health services of the local public health department, following their accepted standards and regulations. The director of food and nutrition services will have a copy of the applicable regulations on file and should be familiar enough with this information to implement policies and procedures to meet the regulations. Note: Not all states require local health department inspections.b. The state and/or federal survey team as part of the annual survey process will inspect the department.2. Employeesa. All staff will be in good health, will have clean personal habits, and will use safe food handling practices.b. Hair restraints are required and should cover all hair on the head. c. [NAME] nets are required when facial hair is visible.3. Leftover Foodsa. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days or discarded as per the 2017 Federal Food Code. Check state regulations as some states may allow shorter time frames for use of leftovers.4. Refrigerated food storage.a. All refrigerator units should be kept clean and in good working condition at all times.b. All foods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded.5. Frozen Foodsa. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. Record review of facility policy Preventing Foodborne Illness - Employee Hygiene and Sanitary dated 2017 reflected: Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. 1. All employees who handle, prepare, or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents.Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Event ID: Facility ID: 675918 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 675918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 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 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 7 residents (Resident #2, Resident #63, and Resident #33) and 2 of 5 staff (LVN C and CNA A) reviewed for infection control. 1. The facility failed to ensure CNA A was conducting hand hygiene between each resident when passing lunch trays on hall 500. 2. The facility failed to ensure LVN C was sanitizing surfaces before and after when providing wound care for Resident #2, Resident #63, and Resident #33.These failures could place residents at risk of transmission of disease and infection. Findings included: Observation on 07/29/25 at 12:21 pm on hall 500 hall revealed CNA A pushed the meal cart down the hall. Without conducting hand hygiene CNA A picked up a tray and brought it to Resident #2's room. CNA A then picked up a tray for Resident #50 and brought it to her room, and no hand hygiene conducted. He then picked up a tray for Resident #71 and brought it to her room, no hand hygiene conducted. CNA A then brought a tray to Resident #46's room, and no hand hygiene conducted. CNA A then picked up a tray and brought it to Resident #72's room, and no hand hygiene conducted. Interview on 07/29/25 at 12:27 with CNA A stated he would wash his hands before starting to assist the residents with eating lunch. CNA A stated he was passing the lunch trays to all the residents right now. CNA A further stated he had received training on hand hygiene. Resident #2Observation on 7/31/25 at 9:05am of wound care for Resident #2 revealed LVN C did not sanitize the resident side table post treatment. Interview on 07/30/25 at 9:13am revealed LVN C stated she was aware that per policy she should sanitize Resident #2's side table that she used for wound care before and after wound treatment. Record review of Resident #2's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included a pressure ulcer of right hip at stage 4, chronic kidney disease, congestive heart failure, and type 2 diabetes mellitus. Record review of Resident #2's Physician Active Orders dated 07/31/25 reflected she had an order for wound care to the right ischium, clean with betadine and pat dry. Apply calcium alginate and cover with dry dressing daily. Resident #2 also had an order for wound care to left ischium and Sacrococcyx, clean with betadine and pat dry. Apply calcium alginate and cover with dry dressing daily. Record review of Resident #2's Care Plan, last revised on 07/21/25, reflected she had a chronic stage 4 pressure ulcer to sacrum, with a goal to facilitate wound healing without complications while reducing the risks for the new areas of breakdown for 90 days. The approach reflected to observe and report signs of sepsis (fever, malaise, change in mental status, tachycardia, hypotension, anorexia, nausea, vomiting and diarrhea). Resident #63Observation on 7/30/25 at 9:17am of wound care for Resident #63 revealed LVN C did not sanitize the nursing treatment cart and resident side table post treatment. Interview on 7/30/25 at 9:27am with LVN C revealed she knew that she is supposed to sanitize the surfaces before and after the wound treatment. She stated she just got nervous and forgot. Record review of Resident #63's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included cerebral infarction, cirrhosis of liver, diabetes mellitus type 2, heart failure, hypothyroidism, and peripheral vascular disease. Record review of Resident #63's Physician Active Orders dated 07/31/25 reflected he had an order for wound care to the right 1st metatarsal (toe) clean with wound cleanser or normal saline, and pat dry. Apply Calcium Alginate/Bactroban and cover with dry dressing daily until healed and PRN for soiling or dislodgement. Monitor wound for signs and symptoms of infection and notify MD. Record review of Resident #63's Care Plan, last revised on 02/05/25, reflected a potential for skin breakdown due to Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675918 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 675918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 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 history of skin breakdown/pressure ulcer, Diabetes, peripheral vascular disease, incontinence, poor activity intolerance/mobility and primarily bed bound state. The goal was for Resident #63 to have intact skin with risks for breakdown minimized to the extent possible for 90 days. Resident #33Observation on 7/30/25 at 9:31am of wound care for Resident #33 revealed LVN C did not sanitize resident side table she used for placing supplies post treatment. Interview on 7/30/25 at 9:45am revealed LVN had forgotten to sanitize Resident #33's side table, and she knew she should have. Record review of Resident #33's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included anemia, need for assistance with personal care, muscle weakness, hyperlipidemia, hypertension, and acquired absence of toe(s). Record review of Resident #33's Physician Active Orders dated 07/31/25 reflected an order for left foot/toes amputation: Clean with normal saline or wound cleanser, and pat dry. Apply Betadine to incision, Calcium alginate with silver, wrap with kerlix and secure with ACE wrap daily and PRN. Record review of Resident #33's Care Plan, last revised on 07/29/25, reflected a pressure ulcer/injury - Resident #33 had a surgical wound to left foot status post amputation of metatarsals. The goal was to conduct wound care as ordered. Interview on 7/31/25 at 5:15 PM with the DON who stated she was responsible for ensuring staff are following infection control measures when providing care for the residents. The DON stated the policy on cleaning surfaces and medical equipment during wound care included using a clean technique, ensuring all surfaces were cleansed with disinfectant, use of the proper materials and equipment, and ensure surfaces and equipment were always clean. The DON stated the surface needed to be disinfected before the barrier/clean field was placed on the surface. She further stated we do not see microorganisms with bare eyes, and not sanitizing the surface of the medication cart and the bedside table used for wound care could result in an infection for the resident. Interview on 7/31/25 at 6:22 PM with the ADMIN revealed the CMAs and nurses were supposed to sign for the narcotic after a triple check and reviewing the five rights of medication administration and complete the sign out after the resident is given the medication. The ADMIN further stated if the count were not correct it could result in a medication shortage, or the ordering process could be off schedule for the resident. The ADMIN stated the DON was the Infection Preventionist, and all the department heads were in-serviced on Infection Control best practices, and we work as a group to ensure everyone in the facility was following Infection Control practices, with special focus on hand hygiene. The ADMIN further stated a potential negative outcome would be the spread of infection if staff members were not following Infection Control guidelines. Record review of facility's policy and procedure, dated August 2016, titled, Infection Prevention and Control Program reflected: Purpose was to ensure the facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements.Staff Training and Competency Evaluation Specific content for Staff Training and Competency Evaluation should include: Chain of infections and methods of transmission Proper cleaning and disinfection of multi-person use equipment, such as blood pressure machines or stethoscopes.Food Service/Kitchen SanitationUnsafe food handling practices can increase the risk of pathogen exposure to residents. Sanitary conditions must be present to promote safe food handling. Record review of facility's policy and procedure, dated 01/19/24, titled, Handwashing/Hand Hygiene, reflected:This facility considers hand hygiene the primary means to prevent the spread of infections.1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene inpreventing the transmission of healthcare-associated infections.2. All personnel shall follow the handwashing/hand hygiene procedures to helpprevent the spread of infections to other personnel, residents, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675918 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 675918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 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 and visitors.7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:o. Before and after eating or handling food.p. Before and after assisting a resident with meals. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675918 If continuation sheet Page 17 of 17