Health inspection·September 13, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few She said he had been homeless. She said when they went to see Resident #1 right before he was discharged from the hospital, he did not know who they were. She said that the police had not come to talk to the FM. She said the facility had called the police when Resident #1 eloped from the facility. During an interview with LVN A on 09/12/2025 at 11:15a.m., revealed she had gone to do her rounds around 6:00am and Resident #1 was in the bed. She said she went back to see if Resident #1 got his breakfast around 8:00am and he was not in the room. She said she checked to see if Resident #1 was in the bathroom, and he was not. She said she then called the ADM. She said she did a head count and staff searched for Resident #1. She said that when she was searching for Resident #1, she noticed the window up and the screen was off. She said with Resident #1 being confused he was considered an elopement risk. She said she did not know why the other nurse did not mark Resident #1 on the elopement assessment as cognitively impaired. She also said she was trained on completing the elopement assessment in the computer in July of 2025. During an interview with LVN B on 09/12/2025 at 11:26a.m., revealed she admitted Resident #1. She said when he came in, he was friendly. She said as soon as EMS dropped him off, he was walking around the facility. She also said that he was not trying to exit the building and did not say he wanted to leave. She said he looked normal but when you had a conversation with him, he could not remember stuff. She said he was confused. She said he could not tell her what day it was, who the president was, and what month it was. She said he did not appear anxious when he was walking around the facility. She said she did not consider him an elopement risk. She also said he did not appear to be one that would elope. She said with Resident #1 on the elopement assessment she would have checked the box that he was cognitively impaired, but he was not going around to the doors or showing he wanted to leave. She said that she had been trained on completing the elopement assessment in the computer in October 2024. During an interview with CNA C on 09/12/2025 at 11:38a.m., revealed that she worked with Resident #1. She said he was admitted to the facility on [DATE]. She said at 6:15a.m., she went into Resident #1's room and introduced herself and he introduced himself. She said he had the cover over his head when she first went into the room and Resident #1 seemed anxious and really confused. She said she showed him how to use the call light and asked Resident #1 if he needed anything before, she left the room. She said he wanted her to close the door when she left. She said that she did consider Resident #1 an elopement risk with how confused he was. During an interview with the RN C on 09/12/2025 at 12:05p.m., revealed staff had been trained on completing the elopement assessments in the new computer system. She said that the facility rolled out the new system mid-July of 2025. She said she did not have any interaction with Resident #1 but saw in his medical records that he was confused. She said she did not know Resident #1 was walking up and down the hall when he got to the facility. She said she did not consider Resident #1 an elopement risk because he did not say he wanted to leave. She said he was aimlessly wandering. She said the box on the elopement assessment for cognitively impaired should have been checked. She said just because he was confused did not make him an elopement risk. She said he would have to have behaviors showing he was an elopement risk. She said he was not going towards the doors or saying he wanted to leave. During an interview with RN D on 09/12/2025 at 3:00p.m., revealed that she had done Resident #1's admission and assessment. She said that Resident #1 got to the facility around 6:00pm and she signed papers for EMS and then introduced herself to Resident #1. She said she did her assessment and asked Resident #1 who the president was, what was the date, and other questions. She said he appeared to know what was going on but when she started talking to him, he did not know what was going on. She said the only question he could answer was his name. She said he did not appear to be anxious or wandering the halls. She said she did the elopement risk and Resident #1 did not appear to be an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675918 If continuation sheet Page 2 of 6 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 09/13/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few elopement risk at that time . She said when she finished with him it was 7:00p.m., she said he did not show her that he was somebody who would be exit seeking. She said he stayed in his room the whole night. She said when she finished with Resident #1, she got him some food for the kitchen. She said on the assessment she should have marked cognitively impaired. She said she overlooked the question. She said the hospital did not give her enough information, and the hospital did not call her and give her a report. During an interview with the MD on 09/12/2025 at 4:04p.m., revealed that she would not expect the staff to increase supervision on the resident due to his medical history of homelessness and drug abuse. She said she would not consider him an elopement risk. She said there were a lot of residents who had strokes and different neurologic disorders, which do not try to elope. She also said it was hard to distinguish who had the capacity of knowing where the risk come from. She also said staff could not predict the resident's behavior or if he was going to elope. She said they encourage residents to walk, and they are safe to move around the facility. She said she would not have staff increase supervision for a new admission for 72 hours. She said staff already round frequently and do regular vitals and medications and then the aids give out medication She said there were a lot of people who their baseline was neurologic conditions and then become confused after they come to the facility. She said they could have been more vigilant in figuring out what happened. During an interview with FM #2 on 09/12/2025 at 12:32pm revealed that Resident #1 had just showed up to FM #1's house. She said Resident #1 was acting aggressive and FM #1 feared him. Record review of Investigation Report for intake dated 9/11/2025 revealed that the facility had a QAPI meeting regarding the incident, CNA C wrote a statement, and the ADM and DON were re-educated by the CN. There was no training done for staff related to elopement. There was no retraining on the elopement assessments. Record review of progress notes dated 09/12/2025 at 1:05pm revealed that the ADM phoned FM #1 of Resident #1 who verified Resident #1 was at her house. FM #1 told the ADM that Resident #1 was agitated and appeared to be under the influence. FM #1 told the ADM that police were at her house and Resident #1 was refusing to go to the hospital. The ADM documented that the police escorted Resident #1 away from FM #1's house a block away the FM's house. Record review of Wandering and Elopements Policy revised March 2019 revealed, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. If a resident is missing, initiate the elopement/missing resident emergency procedure: Determine if the resident is out on an authorized leave or pass; If the resident was not authorized to leave, initiate a search of the building(s) and premises; and if the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative, the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.). This was determined to be an Immediate Jeopardy (IJ) on 09/12/2025 at 5:05p.m. The ADM was notified. The ADM was provided with the IJ template on 09/12/2025 at 5:05p.m. The following Plan of Removal submitted by the facility and was accepted on 09/13/2025 at 12:15 PM. PLAN OF REMOVALF689On 09/12/2025 an abbreviated survey was initiated at facility. On 09/12/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate jeopardy states as follows: The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the alleged issue of elopement risk: Regional [NAME] President of Operations and Regional Nurse Consultant educated the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675918 If continuation sheet Page 3 of 6 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 09/13/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few administrator and DON on recognizing and intervening on potential for elopement on all resident population as well as immediate notification of Administrator, DON, RP, and MD. Initiated: 09/12/2025 Completion: 09/12/2025. The Administrator/Director of Nursing/Designee educated all facility staff on recognizing and intervening on potential for elopement on all resident population as well as immediate notification of Administrator, DON, RP, and MD. Initiated: 09/12/2025 Completion: 09/12/2025. DON/Designee completed an elopement drill for all facility staff. Initiated:9/12/2025. Completion: Ongoing Administrator/Designee secured all resident windows to a maximum opening of 6 inches. Initiated: 09/11/2025 Completion: 09/11/2025 Administrator/Designee assessed all wander guard door alarms, and no issues were identified. Initiated: 09/11/2025 Completion: 09/11/2025 DON was educated by Regional [NAME] President of Operations and Regional Nurse Consultant on accurate completion of elopement evaluation. DON/Designee to re-educate all licensed nurse on accurate completion of the elopement evaluation. Signatures obtained to demonstrate understanding. Initiated: 09/12/2025 Completion: 09/12/2025 DON/Designee completed elopement risk assessments on all residents in facility with no further residents deemed at immediate risk of wandering/elopement risk. Resident in question was found at his sister's house on 09/12/2025. Initiated 9/11/25. Completed 09/11/2025. Staff that are on leave from the facility will be re-educated by Administrator/DON/Designee on elopement risks prior to next shift. This facility does not employ the use of agency personnel. Initiated: 09/12/2025 Completion: Ongoing The policy and procedure already in place for elopement and reporting was reviewed by Regional [NAME] President of Operations and Regional Nurse Consultant with no revisions required. Initiated: 9/12/2025 Completed: 9/12/2025 To prevent future occurrences, Resident #1 was located and decided to discharge from the facility AMA. APS report filed 9/12/25. All residents residing in facility were screened for elopement risk. No additional residents identified. Initiated 9/11/25. Completed 09/11/2025. Facility Administrator discussed findings from survey allegations with medical director to ensure continuation and participation of all practitioners with resident elopement risks. Initiated: 9/12/2025 Completed: 9/12/2025 The Medical Director was notified of Immediate Jeopardy. Initiated: 9/12/2025 Completed: 9/12/2025 Monitoring included: Observations on window in room [ROOM NUMBER] on 09/13/2025 at 11:59am revealed that the window stopped at 6 in. Observations on window in room [ROOM NUMBER] on 09/13/2025 at 12:01pm revealed that the window stopped at 6 in. Observations on window in room [ROOM NUMBER] on 09/13/2025 at 12:04pm revealed that the window stopped at 6 in. Observations on window in room [ROOM NUMBER] on 09/13/2025 at 12:05pm revealed that the window stopped at 6 in. Observations on window in room [ROOM NUMBER] on 09/13/2025 at 12:07pm revealed that the window stopped at 6 in. During an interview with LVN E on 09/13/2025 at 12:38p.m., revealed she had been trained on elopement and completing the elopement assessments. She said the training covered what to do if there was an elopement, what to do to assess the resident and how to answer the questions. She also said she would ask about behaviors. She said elopement was when a resident left the facility without staff and did not sign out. She said signs of an elopement were wandering around the facility pushing on doors and looking for a way out. She said for a new resident staff would look at the resident's chart and elopement assessment to see if the resident was an elopement risk. She said if a resident eloped staff were to call a code yellow, look for the resident in the room, bathroom, closet, under the bed, as well as do a head count and put a trash can in the doorway of a room after it had been searched. She also said staff would look outside the facility around the building, drive around the neighborhoods looking for the resident. She also said staff would call the DON, ADM, MD, and RP. She said if a resident was an elopement risk staff were to call the DON and the MD to get orders for a wander guard. She said she did do the elopement drill and staff were searching and called a code (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675918 If continuation sheet Page 4 of 6 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 09/13/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few yellow. During an interview with CNA F on 09/13/2025 at 1:14p.m., revealed that he had been trained on elopement. He said the training covered what to do if someone was missing. He said staff were to call a code yellow, do a head count of all residents, check rooms, closets and outside and make sure everything was clear. He said elopement was when resident left the facility and did not sign out and staff could not find the Resident. He said staff were to also call the nurse and the ADM and inform them of the missing resident. He said that signs of an elopement risk were pushing doors and asking how to get out. He said if he had a new resident and did not know if the resident were an elopement risk he would look at the resident's chart and ask the nurse about the resident. He said that he did participate in the elopement drill and staff searched for a missing resident and put the trash can in the door once done searching the room.During an interview with CNA G on 09/13/2025 at 1:38p.m., revealed she had been trained on elopement. she said the training covered what to do if someone was missing. She said staff were to search for the resident that was missing. She also said that staff were to call a code yellow and notify the charge nurse. She said signs of elopement were the resident wanting to leave. She said she was in the elopement drill and the ADM had staff searching like a resident was missing. During an interview with LVN H on 09/13/2025 at 1:53p.m., revealed that he had been trained on elopement and completing the elopement assessments. He said that the training covered how to report a resident who is confused and watch new residents what to do and who to notify. He said elopement was when a resident left the facility without notifying staff. He said signs of elopement were when a resident wanders from door to door, confused and going into other residents' rooms. He said to find out if a new resident were an elopement risk he would look at the report from the previous nurse, go check on the resident and observe the resident. He said if a new resident were an elopement risk he would let the DON know and call the doctor to get orders for a wander guard. He said that signs of elopement were a resident and pushing the doors and wanting to leave. He said he did attend the elopement drill and staff looked for residents, did a head count of residents, and called a code yellow. During an interview with LVN I on 09/13/2025 at 2:01p.m., revealed that she was trained on elopement and completing the elopement assessments. She said the training covered what to do when a resident was missing. She also said the training covered when doing the assessment staff were to ask the resident questions and get to know the resident's history. She said that elopement was when a resident left the facility without staff knowledge. She said signs of elopement risk were wandering to the doors, asking to leave, and cognitive impairment. She said if a resident was missing staff were to check the last place the resident was, check the whole facility, rooms, shared areas, bathrooms and outside. She said staff were to notify the DON, ADM, RP, and MD. She said depending on what is found out about the resident would depend on if the staff were to call the doctor and get an order for wander guard. During an interview with CNA J on 09/13/2025 at 2:23p.m., revealed she had been trained on elopement. she said the training covered what to do if a resident was missing. She said that elopement was when the resident left the facility without notice and did not sign out. She said a sign of elopement risk was when a resident would wander to the doors and push on them to get out. She said to find out if a new resident were an elopement risk she would ask the charge nurse about the resident. She said when a resident was missing staff were to call a code yellow, search all halls, all rooms, everywhere. She said staff were to report to the nurse, DON, and ADM if a resident was missing. She said she did participate in the evacuation drill. She said the staff went to all the halls, checked the rooms, the bathrooms, under the beds. She said when staff came out of a room after searching staff would put a trash can in the doorway to show the room had already been searched. During an Interview with the RDO on 09/13/2025 at 2:12pm revealed that he did review the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675918 If continuation sheet Page 5 of 6 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 09/13/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete policy and did not make any revisions to the policy.During an interview with the MD on 09/13/2025 at 2:19pm revealed that the administrator did discuss the finding and ensured continuation and participation of all practitioners with resident elopement risk. Record Review revealed that the RDO re-educated the ADM with CN present on 09/12/2025. The CN educated the DON on 09/12/2025. Record review of Wandering and Elopements, policy Interpretation and Implementation In-service and Elopement Drill revealed that the DON educated staff and conducted an elopement drill with 39 of 90 staff. Record review revealed that wander guard monitoring checklist has been completed for all shifts starting Sept. 1, 2025. Record review of Elopement Evaluation Observation In-service Training dated 09/12/2025 revealed 16 of 34 Licensed Nurses were in-serviced on completing the elopement assessments. Record review of elopement risk assessments revealed 93 0f 93 residents had elopement risks assessments completed. Six residents identified as elopement risk. 6 of 6 residents' elopement risk assessment, care plan and MDS match. Record review revealed some PRN staff have been educated. Record review of AMA dated 09/12/2025 revealed the resident refused to sign.Record review revealed that the medical director was called by the ADM on 09/12/2025 at 1:14pmRecord review revealed that a QAPI meeting was held on 9/11/2025. On 09/12/2025 at 5:05 p.m., an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/13/2025 at 3:00 p.m., the facility remained out of compliance at a severity level of not actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. Event ID: Facility ID: 675918 If continuation sheet Page 6 of 6