Inspection·November 24, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete exceed 3gm of Acetaminophen in 24 hours. RP in facility at this time. Notified this writer that resident does have a fracture to the Rt Humerus from the unwitnessed fall that occurred on 10/16/25. Hospice telephoned for clarification of results of XRAY performed on 10/17/25. Hospice nurse stated resident does have a fracture and will send results via email to Administrator of facility. RP declined ER visit due to resident's decline in health and wishes for facility/hospice to keep resident comfortable at this time. Prn Morphine given at approx. 11:40 am. Review of Resident#1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 09, indicating moderate cognitive impairment. During an interview on 11/07/2025 at the DON stated the facility was aware of Resident #1's right humerus fracture due to a fall on 10/16/2025. The DON stated the X-ray was completed on 10/17/2025 on Resident #1's right arm and was positive for a fracture. The DON stated Resident #1 was on hospice services and Resident #1's RP had declined aggressive treatment to the right humerus fracture. The DON stated Resident #1's right fracture should have been care planned to enable staff to know what interventions to provide for Resident #1. The DON stated the MDS nurse was responsible to update Resident #1's care plan to reflect right humerus fracture with interventions. During an interview on 11/07/2025 at 12:40 pm the MDS Nurse stated she was responsible for completing and updating comprehensive care plan and MDS assessment. The MDS Nurse stated the floor nurses were responsible for doing the acute care plan and they should have done an acute care plan for Resident #'s fracture. The MDS Nurse stated an acute care plan was for something that happened to the resident right away, and examples like falls, fractures and infections, interventions were listed right away. The MDS Nurse stated comprehensive care plans were done whenever there was a resident's assessment, generally quarterly and annually. The MDS nurse stated the Administrator had just asked her to update Resident #1's comprehensive care plan to include risk for fall and fracture. The MDS Nurse later stated care plans were updated for significant changes and fracture was considered a significant change. The MDS Nurse stated, I agree with you. {Resident #1's] comprehensive care plan should have been updated to reflect fracture of her right humerus, but we have 14 days to update the comprehensive care plan for significant change. On 11/07/2025 at about 2:12 pm a request for acute care plans from the DON was made and there was no acute care plan for Resident #1 regarding the fracture of the right humerus. Review of the facility's policy revised December 2016 titled Care Plans, Comprehensive Person-Center reflected: Policy Statement: A comprehensive, person-center care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representatives, develops and implements comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Assessment of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.The Interdisciplinary Team must review and update the care plan:--when there has been a significant change in the residents' condition.--when the desire outcome is not met.--when the resident has been readmitted to the facility from a hospital stay; and --at least quarterly, in conjunction with the required quarterly MDS assessment. Event ID: Facility ID: 675918 If continuation sheet Page 2 of 5 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 11/24/2025 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 0728 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. Based on interview and record review the facility failed to ensure professional staff were licensed certified or registered in accordance with applicable state laws for 13 Nurse Aides of 13 nurse aides reviewed for assessments. The facility failed to ensure NAs A, B, C, D, E, F, G, H, I, J, K ,L ,M, Nurse Aide Curriculum skill performance checklists were checked off. This failure could place residents at risk of not being provided care by qualified staff, which could cause inadequate care and injury resulting in decreased health and psycho-social well-being.Findings include:Record review of NA A's employee record revealed they were hired 10/09/25 as a Nurse Aide trainee. The Nurse Aide Program training was completed on 10/03/25. There was no proof of a Nurse Aide Curriculum skill performance checklist. Record review of NA B's employee record revealed they were hired 09/02/25 as a Nurse Aide trainee. The Nurse Aide Program training was completed on 09/02/25. There was no proof of a Nurse Aide Curriculum skill performance checklist. Record review of NA C's employee record revealed they were hired 09/02/25 as a Nurse Aide trainee. The Nurse Aide Program training was completed on 09/02/25. There was no proof of a Nurse Aide Curriculum skill performance checklist. Record review of NA D's employee record revealed they were hired 09/09/25 as a Nurse Aide trainee. The Nurse Aide Program training was completed on 08/22/25. There was no proof of a Nurse Aide Curriculum skill performance checklist. Record review of NA E's employee record revealed they were hired 09/12/25 as a Nurse Aide trainee. The Nurse Aide Program training was completed on 09/12/25. There was no proof of a Nurse Aide Curriculum skill performance checklist. Record review of NA F's employee record revealed they were hired 08/04/25 as a Nurse Aide trainee. The Nurse Aide Program training was completed on 08/04/25. There was no proof of a Nurse Aide Curriculum skill performance checklist. Record review of NA G's employee record revealed they were hired 09/09/25 as a Nurse Aide trainee. The Nurse Aide Program training was completed on 09/02/25. There was no proof of a Nurse Aide Curriculum skill performance checklist. Record review of NA H's employee record revealed hired 10/09/25 as a Nurse Aide trainee. The Nurse Aide Program training was completed on 09/02/25. There was no proof of Nurse Aide Curriculum skill performance checklist. Record review of NA I's employee record revealed they were hired 10/09/25 as a Nurse Aide trainee. The Nurse Aide Program training was completed on 09/02/25. There was no proof of a Nurse Aide Curriculum skill performance checklist. Record review of NA J's employee record revealed they were hired 09/02/25 as a Nurse Aide trainee. The Nurse Aide Program training was completed on 09/02/25. There was no proof of a Nurse Aide Curriculum skill performance checklist. Record review of NA K's employee record revealed they were hired 10/09/25 as a Nurse Aide trainee. The Nurse Aide Program training was completed on 09/02/25. There was no proof of a Nurse Aide Curriculum skill performance checklist. Record review of NA L's employee record revealed they were hired 09/09/25 as a Nurse Aide trainee. The Nurse Aide Program training was completed on 09/02/25. There was no proof of a Nurse Aide Curriculum skill performance checklist. Record review of NA M's employee record revealed they were hired 08/13/25 as a Nurse Aide trainee. The Nurse Aide Program training was completed on 08/08/25. There was no proof of a Nurse Aide Curriculum skill performance checklist. Interview on 11/24/25 at 3:48 PM, the DON stated the Staffing Coordinator was responsible for checking the student NAs off once they completed a skills task. The DON stated that each NA student's skills had been checked off but was unable to locate the binder. The DON stated the entire facility was checked and they were unsuccessful in locating. The DON stated all 13 NA students would be re-checked and the binder would be kept in her office. The DON stated it was expected for the binder with the NAs training to be presented for review. The DON stated that without providing the training binder it would look like (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675918 If continuation sheet Page 3 of 5 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 11/24/2025 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 0728 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the training check offs would not have been completed. The DON stated it was expected for the NAs training check off to be completed and validated.Interview on 11/24/25 at 3:56 PM, the ADM stated it was expected for the NAs skill check off binder to be kept up to date and available when asked for. The ADM stated the Staffing Coordinator was responsible for checking off the NAs' skills completed. The ADM stated the binder that kept that skill performances check offs was not able to be located in the facility. The ADM stated the Staffing Coordinator was responsible for checking off the student NAs. The ADM stated if the binder with the check was not able to be presented it would look like they were not done. It was expected for the checkoffs to be presented to ensure the student NAs were able to care for the residents.Interview on 11/24/25 at 4:52 PM, the Staffing Coordinator stated she was responsible for making sure student NAs were checked off once they completed the skills. The Staffing Coordinator stated the binder with the checkoffs was not able to be located. The Staffing Coordinator stated the skills performance checklist on the NAs was completed and it was expected for the binder to be presented when asked to validate that the skills had been checked off on. The Staffing Coordinator stated the skills performance for the NAs was not accounted for and without able to present would indicate that the skill checks were not done. 1. Record review of the facility's Nurse Aide Qualification and training requirements dated 2001 revised 2019, revealed Nurse Aide must undergo a state approved training program. 2. Applicants who meet the qualifications for a nurse aide and are in training will have a minimum of 16 hours of training in the following areas prior to direct contact with the residents:a. Communication and interpersonal skills.b. Infection control.c. Safety/emergency procedures.d. Promoting residents' independence.e. Respecting residents' rights.f. Basic nursing skills (including):(1) Taking and recording vital signs.(2) Measuring and recording height and weight.(3) Caring for the residents' environment.(4) Recognizing abnormal changes in body functioning and the importance of reporting such changes to a supervisor; and(5) Caring for residents when death is imminent.g. Personal care skills (including):(1) Bathing;(2) Grooming, including mouth care;(3) Dressing;(4) Toileting;(5) Assisting with eating and hydration;(6) Proper feeding techniques;(7) Skin care; and(8) Transfers, positioning, and turning.h. Mental health and social service needs (including):(1) Modifying aide's behavior in response to residents' behavior;(2) Awareness of developmental tasks associated with the aging process;(3) How to respond to resident behavior;(4) Allowing the resident to make personal choices, providing and reinforcing other behavior consistent with the resident's dignity; and(5) Using the resident's family as a source of emotional support.I Care of cognitively impaired residents (including):(1) Techniques for addressing the unique needs and behaviors of individuals with dementia (Alzheimer's and others);(2) Communicating with cognitively impaired residents;(3) Understanding the behavior of cognitively impaired residents;(4) Appropriate responses to the behavior of cognitively impaired residents; and(5) Methods of reducing the effects of cognitive impairments.J. Basic restorative services (including):(1) Training the resident in self care according to the resident's abilities;(2) Use of assistive devices in transferring, ambulation, eating, and dressing;(3) Maintenance of range of motion;(4) Proper turning and positioning in bed and chair;(5) Bowel and bladder training; and(6) Care and use of prosthetic and orthotic devices. k. Resident rights (including):(1) Providing privacy and maintenance of confidentiality;(2) Promoting the residents' rights to make personal choices to accommodate their needs;(3) Giving assistance in resolving grievances and disputes;(4) Providing needed assistance in getting to and participating in resident and family groups and other activities;(5) Maintaining care and security of residents' personal possessions;(6) Promoting the resident's right to be free from abuse, mistreatment, and neglect and the need to report any instances of such treatment to appropriate facility staff; and(7) Avoiding the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675918 If continuation sheet Page 4 of 5 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 11/24/2025 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 0728 need for restraints in accordance with current professional standards. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675918 If continuation sheet Page 5 of 5