Granbury Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 3 of 7 residents (Resident #3, Resident #4, and Resident #6) reviewed for accurate records. 1. The facility failed to have documentation to indicate why Resident #3's medications were not given on 07/15/2026. (Ivermectin and Spinosad), and 07/16/2026 (Spinosad). The facility failed to document when Ivermectin was administered.2. The facility failed to have documentation to indicate why Resident #6's medications were not given on 07/15/2026 (Ivermectin and Spinosad), and on 07/16/2026 (Spinosad).3. The facility failed to have physician's order for Spinosad's administration to Resident #3, Resident #4, and Resident #6 on 07/25/2026.4. [...]

Inspectors wroteBased on interviews and record review, the facility failed to complete a comprehensive assessment within 14 days after admission to the facility, for 1 of 7 (Resident #6) residents reviewed for comprehensive assessments. The facility failed to complete Resident #5's comprehensive admission MDS assessment within 14 days after admission. This failure could place residents at risk of not having their care and treatment needs assessed to ensure necessary care and services were provided.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of any significant medication error reviewed 5 of 5 (LVN E, LVN I, LVN J, LVN K and ADON A) staff reviewed for Insulin use. The facility failed to ensure LVN E held Resident #102's Lantus 100 Units/ML two (2) times when his blood glucose was under 120 for a two (2)-month review period. The facility failed to ensure LVN I held Resident #102's Lantus 100 Units/ML thirteen (13) times when his blood glucose was under 120 for a two (2)-month review period. The facility failed to ensure LVN J held Resident #102's Lantus 100 Units/ML three (3) times when his blood glucose was under 120 for a two (2)-month review period. The facility failed to ensure LVN K held Resident #102's Lantus 100 Units/ML six (6) times when his blood glucose was under 120 for a two (2)-month review period. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed food safety. The facility failed to ensure foods were properly labeled in the kitchen. This failure could place residents at risk for food borne illnesses.

Inspectors wroteBased on interview and record review the facility failed ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 26 residents (Resident #6) reviewed for accurate records.1. The facility failed to have documentation to indicate why Resident #6's long-acting insulin (insulin glargine) was held when chart codes indicated see nurse notes.2. The facility failed to have parameter for Resident #6's long-acting insulin (insulin glargine) documented in physician orders. These failures could place residents of an accurate depiction of care in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure regular inspections were conducted of all bed frames, mattresses, and bed rails, as part of a regular maintenance program to identify areas of possible entrapment for 3 of 4 residents (Resident #7, Resident #22 and Resident #48) reviewed for physical environment. The facility failed to conduct regular inspections of resident side rails, bed frames and mattresses to identify entrapment risks for Resident #7, Resident #22, and Resident #48. This failure could place residents at risk of injury, equipment malfunction, entrapment, or falls.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident had the right to be informed of, and participate in, his or her treatment including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he/ she preferred for 1 of 6 residents (Resident #8) reviewed for antipsychotic consents. The facility failed to ensure Resident #8 or their representative signed consent for antipsychotic medication aripiprazole (an antipsychotic medication used to treat mental health disorders, such as schizophrenia) prior to administering medication after dosage increased and prior to administering new dosage ordered by physician. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days, except if the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the residents medical record and indicate the duration for the PRN order for 2 of 7 residents reviewed for unnecessary medications. The facility failed to ensure Resident #40's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or document a rationale for the continued provision of the medication. The facility failed to ensure Resident #117's PRN Diazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or document a rationale for the continued provision of the medication. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to review the risks and benefits of bed rails with the resident or a resident representative and obtain informed consent prior to installation for 1 of 4 residents (Resident #22) reviewed for bed rail consents. The facility failed to obtain informed consent from Resident #22 or her representative or maintain evidence that Resident #22 or her representative had been provided with sufficient information so that they could make an informed decision prior to installing bed rails. This failure could place residents at risk for not being able to make an informed decision due to not having sufficient information on the risks of bed rail usage.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable and, in accordance with State and Federal laws, drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 26 residents (Resident # 25)reviewed for label and storage of drugs and biologicals. The facility failed to ensure Resident #25's medications were locked and labeled when unattended. This failure could place residents at risk of having access to unauthorized medications, leading to possible harm or drug diversions.

Inspectors wroteBased on interview and record review the facility failed to ensure that a resident received CPR in accordance with professional standards of practice for one (Resident #1) of six resident's reviewed for CPR. On [DATE] at 12:20 am, LVN A failed to initiate CPR on Resident #1 who was a full code status. Resident #1 expired on [DATE]. An Immediate Jeopardy was identified on [DATE] at 5:00 pm. The noncompliance began on [DATE] and ended on [DATE]. It was determined to be past non-compliance due to the facility having implemented action that corrected the non-compliance prior to the beginning of the investigation. This failure could affect residents who are full code status and could need CPR by placing them at risk of death.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to a meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #6, Resident #7) of 8 residents reviewed for comprehensive person-centered care plans.1. The facility failed to develop care plans based on assessed needs with measurable objectives in the areas of Hemiplegia/Hemiparesis, Hypertension, GERD, Dementia, and Anxiety for Resident #1.2. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to make sure that the comprehensive care plan was prepared by an interdisciplinary team that included a nurse aide with responsibility for the resident for 8 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, and Resident #8) of 8 residents reviewed for care plans. The facility failed to ensure the nurse aides with responsibility for the residents were invited and attended the resident care plan conferences. These failures could place the residents at risk for not receiving the care and services to meet their needs.

Inspectors wroteBased on observations, interview, and record review the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurate for 3 (Resident #1, Resident #3 and Resident # 7) of 7 residents reviewed for resident records. The facility failed to ensure weekly skin assessments were documented in the medical record for Resident #1, Resident #3, and Resident # 7. This failure could place residents at risk of having errors in care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free from accident hazards as was possible and each resident received adequate supervision and assistive devices to prevent accidents for 2 of 5 residents (Resident #1 & Resident #2) reviewed for accidents and supervision. 1. The facility failed to ensure Resident #1, and Resident #2 were properly supervised during smoke break to prevent agitation and altercations. These failures could place the residents at risk of injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for one (Resident #1) of three residents reviewed for infection control practices. The facility failed to ensure CNA A performed proper hand hygiene and glove changes while providing incontinence care to Resident #1. This failure could place residents at risk for the spread of infection.

Inspectors wroteBased on interview and record review the facility failed to ensure residents/resident's representative had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he/ she preferred for 2 of 26 residents (Resident #50 and Resident #114) reviewed for antipsychotic consents. 1. The facility failed to ensure Resident #50's HHSC Form 3713 for Ziprasidone (also known as Geodon an antipsychotic medication used to treat bipolar 1 disorder and schizophrenia) was signed by Resident #50 or Resident 50'ss responsible party. 2. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to refer residents for PASRR screening and evaluation, with a newly evident mental disorder or related condition for level II PASRR review, 1 of 3 residents (Resident #107) in that: Resident #107 was not referred to the state-designated authority for PASRR re-evaluation upon evidence of past history significant for depression, anxiety, and PTSD when admitted to the facility on [DATE] with a negative PL1. This failure placed residents at risk of not receiving adequate services or care related to mental illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions for 2 of 6 medication carts (Hall B nurse medication cart & Hall A-D nurse medication cart) reviewed for medication labeling and storage. The facility failed to ensure Schedule II-V medications subject to abuse were stored so that shortage of medication was readily detectable for 1 of 2 medication rooms (Hall G-H medication room) reviewed for medication labeling and storage. 1. The facility failed to dispose of expired medications from Hall A-D nurse medication cart. 2. The facility failed to have pharmacy labels on 2 insulin flex pens from Hall B nurse medication cart. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for 4 of 26 Residents (Residents #8, #9, #120, and #376) and one (1) of one (1) kitchen. 1. Residents #8, #9, #120, and #376 voiced concerns of cold food, flavor, and/or texture. 2. One (1) of the three (3) foods sampled on the meal tray was cold. These failures could affect the residents by placing them at risk for malnutrition due to residents' decline in consumption in food, dissatisfaction of meals served, and residents to have unwanted weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for service safety, in that: 1. The facility failed to ensure staff wore effective hair restraints. 2. The facility failed to ensure staff practiced appropriate hand hygiene during meal prep. These failures could place residents at risk of food borne illness and cross contamination. During an observation on 12/02/2024 at 10:45 a.m., [NAME] G cut a large sheet cake with no gloves on. [NAME] G had white tipped acrylic nails on her fingertips approximately ¼ inch in length. [NAME] G touched the cake with her left thumb on the left bottom of the pan as she held the pan to steady to cut. [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, 1 of 5 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to develop a comprehensive care plan for Resident # 1 that included the edema in his lower extremities and resisting care. This failure could place the resident at risk for a decline in health and providers not having the most current information for the Resident's plan of care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for resident records. The facility failed to ensure LVN A and documented accurate skin assessments for Resident #1. These failures could place residents at risk of new or worsening pressure injuries, and not receiving required treatments and medications as ordered by the physician.

Inspectors wroteBased on interview and record review, the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative when there was an accident involving the resident which resulted in injury and had the potential for requiring physician intervention, a significant change in the resident's physical, mental or psychosocial status, or a decision to transfer or discharge the resident from the facility for 1 (Resident #1) of 4 residents reviewed for notification of changes. The facility failed to ensure Resident #1's POA/resident representative was immediately notified when the resident had a change in condition that required her to be transported via ambulance to the hospital. The non-compliance was identified as PNC. The noncompliance began on 07/26/2027 and ended on 07/27/2027. [...]

Inspectors wroteBased on interview, and record review, the facility the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, which were complete and accurately documented for 1 (Resident #1) of 4 residents reviewed for documentation. RN B failed to accurately document the notification of Resident #1's resident representative when Resident #1 had a change in condition and was sent via ambulance to the hospital. This failure could place residents at risk of inaccurate documentation in residents' records and decreased confidence in the facility staff.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 2 (Resident #3 and Resident #7) of 6 residents reviewed who required working call lights for quality of care. The facility failed to ensure the call light in Resident #3 and Resident #7's room was in good working order. The string to activate call light was long enough to be within reach of residents in room. This failure could place residents at risk of not being able to alert staff to their room.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the resident environment remained as free from accident hazards as was possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 20 residents (Resident #1) reviewed for accidents and supervision. CNA A failed to ensure Resident #1 was properly transferred by two persons using a Hoyer Lift to prevent accidents. This failure could place the residents at risk of injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 2 (Resident #1 and Resident #2) of 10 residents reviewed for multiple falls. The facility failed to implement a system for identifying fall patterns and implementing interventions to prevent falls that lead to emergency room visits with serious injury on 12/17/2023 and 02/07/2024 for Resident #1 and 12/10/2023 and 01/04/2024 for Resident #2. An IJ was identified on 02/16/2024. The IJ template was provided to the facility on [DATE] at 10:25 am. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident #1 and Resident #3) of 10 Residents reviewed for accuracy of assessments. - The facility failed to ensure the Quarterly MDS dated [DATE] reflected falls and Significant Change MDS dated [DATE] reflected accurate number of falls for Resident #1. - The facility failed to ensure the Significant Change MDS dated [DATE] reflected accurate number of falls for Resident #3. This failure could place residents at risk of inaccurate assessments and not receiving appropriate care according to their status.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan based on assessed needs with measurable objectives that have the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Resident #1, Resident #2, and Resident #3) of 10 residents reviewed for comprehensive person-centered care plans. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in areas such as impaired visual function, Seizure Disorder, and risk for falls for Resident #1. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in areas such as hypertension, Diabetes Mellitus, and risk for falls for Resident #2. [...]

Inspectors wroteBased on interviews, observation, and record reviews, the facility failed to ensure the comprehensive care plan were prepared by an interdisciplinary team, that included but not limited to, a nurse aide or a registered nurse with responsibility for the resident for 3 (Resident #1, Resident #2, and Resident #3) of 10 residents reviewed for care plans. The facility failed to invite and include the input of the nursing staff as members of the interdisciplinary team after the completion of the comprehensive assessment for Resident #1, Resident #2, and Resident #3. This failure could place the residents at risk for decreased quality of life and not having their needs met.

Inspectors wroteBased on interview and records review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to implement an appropriate action plan to address identified quality deficiencies for 1 of 1 facility. The QAPI committee failed to implement the corrective actions outlined on the Plan of Correction dated 12/13/2023 for deficient practice F657. This failure placed residents at risk for substandard quality of care due to the failure of the facility to take action on an identified problem affecting resident safety.

Inspectors wroteBased on interviews, observation, and record reviews, the facility failed to ensure the comprehensive care plan were prepared by a interdisciplinary team, that included but not limited to, a nurse aide with responsibility for the resident for 3 (Resident #5, Resident #6, and Resident #8) of 40 residents reviewed for care plans. The facility failed to invite and include the input of the nursing staff as members of the interdisciplinary team after the completion of the comprehensive assessment for Resident #5, Resident #6, and Resident #8. This failure could place the residents at risk for decreased quality of life and not having their needs met.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 (Hall G medication cart and Hall E medication cart) of 6 medication carts reviewed for medication labeling and storage. The facility failed to ensure that insulin stored on Hall G and Hall E's medication cart were properly labeled and not past the medications' expiration date. These failures could place residents at risk of harm or decline in health due to lack of potency of medications/biologicals.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for 1 of 1 kitchen's reviewed for food service safety. The facility failed to properly label food items in the refrigerators, and freezers. The facility failed to discard food items after the use by date in refrigerators and freezers. The facility failed to seal items to protect them from freezer burn in freezers. The facility failed to discard expired food items in the dry food storage areas. The facility failed to maintain clean, refrigerators and freezers. The facility staff failed to practice good hand hygiene while preparing and serving food. These failures placed residents at risk of food borne illnesses that ate from the facility kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically transmitted to the CMS System for 1 (Resident #84) of 3 residents records reviewed for closed records. The facility did not ensure the discharge MDS assessment was completed and electronically transmitted as required for Resident #84. This failure could place residents at risk of facility not providing complete and specific information for payment and quality of measure purposes.

Inspectors wroteBased on interviews and record reviews, the facility failed to accurately reflect the resident's status on the Discharge MDS for 1 (Resident #134) of 3 residents reviewed for closed records. The facility failed to properly code Resident #134's Discharge MDS assessment a 04 for discharge to short-term general hospital instead of 01 for discharged home. This deficient practice could result in missed or inaccurate care.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitization The facility failed to ensure that kitchen staff obtained food temperatures prior to serving meals on 09/04/2023, 09/14/2023,09/15/2023, 09/19/2023, 09/20/2023, 09/24/2023, 09/27/2023, 09/28/2023, 09/29/2023, 09/30/2023, 10/01/2023, 10/02/2023, and 10/03/2023. The facility failed to ensure plastic drinking cups were cleaned and sanitized properly. These failures could place residents that eat out of the kitchen at risk for food borne illnesses.