Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Granbury during CMS and state inspections, most recent first.
RN coverage was not documented for multiple days reviewed, and PBJ Staffing Data showed no RN hours reported to CMS on those dates. The DON said he expected 8 hours of RN coverage daily and noted a weekend RN supervisor helped cover weekends, while the ADMN could not find evidence that an RN worked 8 consecutive hours on the dates in question. Facility policy required an RN to provide services at least 8 hours every 24 hours, seven days a week.
Resident Council Grievances Not Documented or Addressed: The facility failed to consider resident council concerns or show responses to grievances for 10 of 10 council members reviewed. All 10 residents stated they did not feel their views were taken into account or that complaints were followed up, and the ADMN reported there was no grievance documentation available for several months and no resident council meetings since she began in the role.
Food storage, preparation, and service practices were not followed in the kitchen. Surveyors observed multiple unlabeled, undated, unsealed, and expired food items in refrigerators, dry storage, and freezers. During prep, a hot pad fell into soup, and an employee failed to wash hands between tasks while using the same gloves to handle and serve ready-to-eat foods. Interviews and facility policies confirmed that hand hygiene, glove changes, and proper labeling, dating, and sealing of food were required.
QAPI Committee Lacked Required MD Participation: The facility failed to maintain a QAPI committee with the required members because the MD, or a representative, did not attend multiple QAPI meetings reviewed. Record review showed no evidence of MD attendance at the meetings, and the ADM stated she expected the MD to attend and did not know why he had not been present. The facility policy required an ongoing, facility-wide, data-driven QAPI program focused on resident outcomes and quality of life.
Infection Control Failures During Catheter and Incontinent Care: Two CNAs provided incontinent care and foley catheter care to a resident with an indwelling catheter and EBP orders without wearing gowns, repeatedly used the same wipe across multiple body areas and the catheter tubing, and moved from soiled to clean tasks without changing gloves or performing hand hygiene. The DON stated staff should have followed EBP, glove changes, and hand hygiene requirements during high-contact care.
MDS Did Not Accurately Reflect Condom Catheter Use: A resident with multiple diagnoses, including stroke, hemiplegia, and heart failure, had quarterly MDS assessments that did not accurately code his condom catheter use. One assessment showed both indwelling and external catheter use, while a later assessment coded no appliance at all, despite the care plan identifying the external catheter and the resident stating he used it to keep clothing and linens dry and needed staff help with changes.
A resident with bipolar disorder, MDD, PTSD, and psychotropic medication orders had a PASRR Level I screening that was positive for MI, but the facility did not refer the resident for PASRR Level II evaluation or follow up with the LA. The care plan noted psychotropic medication risk, but there was no evidence the bipolar diagnosis was being addressed. The DON said PASRR information was expected to be accurate and that the lapse was due to human error.
Care Plan Did Not Address Smoking Status: A resident with stroke, R-sided paralysis, RA, schizophrenia, seizures, and blindness was observed smoking in the designated smoking area, but his comprehensive care plan did not address tobacco use. Staff, including the DON and Administrator, acknowledged that smoking status should have been included on the care plan, and the resident was identified as a smoker despite the MDS indicating no current tobacco use.
Unlocked Medication Cart Left Unattended: The West Hall medication cart was observed unlocked and unattended near the nurses' station while two residents were nearby and no nurse was on the hall. The cart contained OTC meds, prescription meds, alcohol swabs, sharps, and other supplies in multiple drawers, with narcotics stored in a separate locked drawer. The DON stated carts should be locked when not attended, and the LVN responsible for the cart said she had left it unlocked while helping a resident who fell.
Menu Substitutions Not Communicated to Residents: The facility did not follow the posted lunch menu for several residents when tortilla soup was replaced with tomato soup, and residents were not told about the change. A resident with malnutrition, a resident with DM, and a resident with anemia were observed receiving the substituted soup, and one resident stated he would not eat it because he disliked cooked vegetables. The DM said the soup problem required disposal of the remaining tortilla soup and that she did not notify residents or nursing staff of the substitution.
QAPI Failure to Address RN Coverage Deficiency: The facility’s QAPI committee did not implement an effective action plan after a cited F727 deficiency for failure to provide RN coverage for 8 consecutive hours a day, 7 days a week. Record review showed missed RN coverage on multiple dates, and the ADMN could not provide evidence that an RN worked the required hours on those days. The facility’s QAPI policy required tracking, analysis, corrective action, and monitoring of quality deficiencies.
Surveyors found that the facility failed to develop and implement comprehensive, person‑centered care plans with measurable objectives and timeframes for six residents with complex medical, cognitive, behavioral, and psychosocial needs. For residents with conditions such as dementia, schizophrenia, quadriplegia, COPD, CHF, terminal cancer, chronic pain, and multiple medication regimens, care plans used generic goals like maintaining current function, remaining free from complications, or showing wound improvement, without defining specific, quantifiable criteria or individualized targets. One resident’s MDS showed intact cognition, another showed moderate cognitive impairment, and another could not complete the BIMS, yet in all cases the care plans lacked measurable, resident‑specific objectives for identified issues including falls, infection risk, behavior and self‑harm, nutrition, pain, psychosocial adjustment, respiratory status, and medication side effects. Staff interviews confirmed that the MDS Coordinator and IDT were responsible for ensuring person‑centered, measurable objectives, and that they were aware the existing objectives did not meet these standards, despite a facility policy requiring comprehensive person‑centered care plans with measurable objectives and timetables.
A resident with post-traumatic seizures, schizoaffective disorder, generalized anxiety, schizophrenia, and unspecified intellectual disability was admitted under a Preadmission category after a PL1 screening indicated suspicion of both MI and ID, but without completion of the required PASRR Level II evaluation and determination. The PL1 identified the Texas Department of Criminal Justice as the referring entity and documented positive indicators for MI and ID, which should have triggered a Level II assessment before admission. During a CHOW, the LMHA/LIDDA informed the facility they could not process PASRRs in the TMHP LTC Online Portal due to the lack of a provider number, and Level II assessments were not being completed. The Regional Nurse Consultant acknowledged knowing that PASRR-positive Preadmission individuals could not be admitted before Level II completion, while the Administrator was unaware that Level II assessments were not occurring and that a PASRR-positive Preadmission resident had been admitted. The Marketing Director ensured PL1 completion but did not handle LMHA/LIDDA follow-up, and the MDS Coordinator maintained a list of PL1-positive admissions during the CHOW, believing they could be admitted despite knowing that Preadmission PASRR-positive individuals required a completed Level II assessment before admission.
The facility did not ensure 8-hour RN coverage each day as required, with five days in one month lacking evidence of RN presence. Both the DON and Administrator confirmed the deficiency, attributing it to staffing challenges and difficulties hiring RNs for the facility's resident population. No specific adverse effects on residents were reported.
The facility did not ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. Observations and interviews revealed that a meal was served with cold and unappetizing food, including overcooked rolls, thin gravy, and improperly presented cake. A resident refused to eat due to the food's appearance, and staff acknowledged that food was not maintained at the correct temperature during service.
A resident with multiple health conditions suffered neglect in a LTC facility, resulting in a skin tear that was left untreated for several days. The wound became infested with maggots, discovered by the resident's family. Despite the resident's return from the ER, the facility failed to obtain treatment orders or provide wound care until days later, highlighting significant lapses in care and communication among staff.
A resident with a reopened skin tear on their elbow did not receive timely wound care, resulting in maggots being found in the wound. Despite returning from the ER with a bandage, the facility failed to obtain treatment orders or provide care until several days later. Interviews revealed a lack of communication and follow-up, leading to an Immediate Jeopardy situation.
A resident returned from the ER with a bandaged elbow, but the LTC facility failed to document the bandage or provide wound care, leading to maggot infestation. The resident's medical records lacked documentation of wound care, and the family member had to clean the wound due to staff shortages. Interviews revealed no wound care orders were in place until days later, violating the facility's documentation policy.
The facility failed to develop comprehensive care plans for two residents, omitting critical details such as a resident's DNR status and another's probation conditions. The care plans lacked measurable objectives for addressing specific needs, including wound care. The DON acknowledged these oversights, which were contrary to the facility's policy requiring detailed and measurable care plans.
The facility failed to maintain RN coverage for 8 consecutive hours daily on several occasions due to hiring challenges related to its location. This deficiency was identified through a review of staffing reports and confirmed by interviews with the DON and ADMN, who acknowledged the issue as inherited and primarily affecting weekends.
The facility failed to provide a pureed roll to residents on a pureed diet, as observed during a lunch meal. Three residents with various medical conditions requiring mechanically altered diets did not receive the roll, despite it being listed on their meal tickets. Interviews revealed that the dietician and dietary manager expected all menu items to be served, but the omission was attributed to kitchen staff nervousness. The administrator acknowledged the oversight and its potential impact on residents' nutrition.
The facility failed to properly store, prepare, and serve food, leading to potential risks for foodborne illnesses. Observations showed improper sealing and labeling of food, expired items, incorrect thawing methods, and inadequate temperature control. Staff interviews revealed a lack of adherence to facility policies, possibly due to insufficient education and monitoring.
The facility failed to ensure call lights were within reach for two residents, both of whom required assistance for mobility and had impaired communication or cognitive abilities. One resident's call light was left on a nightstand, while another's was placed on an oxygen concentrator, both out of reach. Staff acknowledged the oversight, and the DON confirmed the expectation for call lights to be accessible.
The facility failed to ensure proper execution of advance directives for two residents, resulting in incomplete OOH-DNR orders lacking necessary witness signatures and missing physician orders for DNR status. Staff interviews revealed a lack of understanding of current rules, with the SW responsible for DNRs not up to date, leading to potential misalignment with residents' preferences.
A facility failed to provide a comprehensive discharge summary for a resident, including a recapitulation of the stay, medication reconciliation, and a discharge plan of care. The resident, with multiple diagnoses, was discharged without necessary documentation and planning. Staff interviews revealed a lack of clarity and responsibility in the discharge process, with the LVN and social worker unable to recall specifics, and the DON acknowledging the oversight.
The facility failed to maintain certain resident rooms in a certified and resident-ready state. Rooms intended for resident use were repurposed for activities, theater, and therapy, with shared walls removed, making them unsuitable for immediate resident care. The administrator admitted to not decertifying the beds and lacked a policy on bed certification.
RN Coverage Not Documented on Multiple Days
Penalty
Summary
The facility failed to ensure the use of a registered nurse for at least 8 consecutive hours a day, seven days a week on 5 of 92 days reviewed for RN coverage: 1/03/2026, 1/24/2026, 1/25/2026, 1/31/2026, and 3/13/2026. Review of the PBJ Staffing Data Report FY Quarter 2 2026 (January 1 - March 31) showed no RN hours were reported to CMS on those dates. During interview, the DON stated his expectation was to have RN coverage 8 hours a day and said he started working at the facility on 3/16/2026, working every day since then. He stated the previous DON’s last day was 3/13/2026 and he was unsure why no RN hours were reported before he started. He also stated there was a weekend supervisor who was an RN and had worked at the facility to help ensure 8 hours of RN coverage on weekends. The ADMN stated she knew of an email thread in which the previous ADMN told him he did not report RN hours appropriately, and she believed the facility had RN coverage. However, after reviewing nurse schedules and a SharePoint site, she was unable to find evidence that an RN worked 8 consecutive hours for the dates in question. She also found a QAPI meeting note stating the previous ADMN documented the facility had 31 days of RN coverage in January 2026. The facility policy stated an RN provides services at least 8 hours every 24 hours, seven days a week.
Resident Council Grievances Not Documented or Addressed
Penalty
Summary
The facility failed to consider the views of the resident council and act promptly on grievances and recommendations concerning resident care and life in the facility, and it did not demonstrate its response or rationale for its response for 10 of 10 confidential resident council members reviewed. During a confidential group meeting and confidential time, all 10 resident council members stated they did not feel the facility took their views and concerns into account and did not follow up when grievances and complaints were expressed. The facility also failed to provide a grievance log for January 2026 through June 2026 showing a verbal or written response to the Resident Council regarding grievances reported from meetings. During interview, the ADMN stated she would expect documentation of grievances, that managers would discuss them in morning meetings, and that she would follow up with the person who made the grievance after it was completed. She stated she started working on 06/29/2026 and did not have documentation from January 2026 to 06/29/2026, and she reported there had not been a resident council meeting since she had been the ADMN.
Food Storage, Hand Hygiene, and Cross-Contamination Failures
Penalty
Summary
The facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards during kitchen observations and record review. In Refrigerator #11, surveyors observed an open plastic container of chicken noodle with a cracked lid, an unopened package of potatoes without a food item description, and other items in dry storage and freezers that were not sealed, labeled, or dated, including cans of cheddar cheese and chicken noodle soup, pasta noodles, powdered sugar, creamy wheat, cereal containers, mustard, cake mix, frosting, frozen biscuits, frozen broccoli, and frozen mango. The report also noted that some items were past their use-by date, and the facility’s matrix showed every resident ate out of the kitchen. During food preparation, the DM dropped a hot pad into prepared soup, and the cook initially planned to pour the remainder of the soup into the pot until questioned about cross contamination. The contaminated soup was then discarded and an alternative soup was prepared. During another observation, [NAME] E failed to wash his hands after preparing puree food in the blender and after preparing food on the stove. The cook used the same gloves to prepare and serve food and picked up ready-to-eat items with gloved hands while plating food. Interviews confirmed that hand hygiene should occur between tasks and after glove removal, that gloves should be changed between tasks, and that the hot pad in the soup and handling ready-to-eat foods with the same gloves were cross contamination concerns. The DM and dietician stated that food items should be labeled, dated, and sealed, and that items past their best-by or use-by date should have been discarded. Facility policies reviewed also required hand hygiene after contaminated surfaces and glove removal, and required food to be labeled, dated, covered, and stored properly.
QAPI Committee Lacked Required MD Participation
Penalty
Summary
The facility failed to maintain a quality assessment and assurance committee with the required members for 10 of 11 QAPI meetings reviewed. Record review of the sign-in sheets for the September 2025 through June 2026 QAPI meetings showed no evidence that the MD attended any of those meetings. The report states that the facility did not ensure the MD, or a representative, attended the QAPI meetings during that period. During an interview on 07.16.2026 at 1:00 pm, the ADM stated her expectation was that the MD would attend QAPI meetings and that it would be beneficial if he attended every meeting. The ADM stated she did not know why the MD had not attended the QAPI meetings and stated she did not feel that his absence had any effect on resident care. The facility policy titled Quality Assurance and Performance Improvement (QAPI) Program states the facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program focused on indicators of outcomes of care and quality of life for residents.
Infection Control Failures During Catheter and Incontinent Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program for a resident with an indwelling urinary catheter and a history of urinary retention and UTI. Resident #58 was documented as having moderate cognitive impairment, being dependent on staff for toileting hygiene, and using an indwelling catheter. The resident also had an order for Enhanced Barrier Precautions (EBP) requiring staff to use gown and gloves during high-contact care activities that could transfer MDROs to hands and clothing. During an observation of incontinent care and foley catheter care, CNA B and CNA C entered the room with supplies in a plastic bag, sanitized their hands, and put on gloves, but no gowns were applied despite the EBP sign on the door and PPE being available in the room. CNA B performed perineal and catheter care while repeatedly using the same wipe over multiple areas, including the inner thighs, penile shaft, scrotal area, buttocks, and catheter tubing. CNA B also touched the catheter tubing with the same wipe used on the resident's skin and continued wiping back and forth over the tubing and skin. CNA C assisted with trash disposal and handling supplies during the care. The observation also showed CNA B moving from dirty to clean tasks without removing gloves or performing hand hygiene, including placing clean linen and a clean brief while still wearing the same gloves used for soiled care and reaching into her pocket for a plastic bag without changing gloves or sanitizing hands. CNA C stated she had been trained on infection control and acknowledged that wiping an area multiple times with the same wipe was not appropriate, that a gown should have been worn during catheter care, and that gloves and hand hygiene should have been changed when moving from dirty to clean tasks. CNA B stated she had been trained on infection control but believed using the same folded wipe multiple times was appropriate, while the DON stated staff should have worn gowns for high-contact care, changed gloves, and performed hand hygiene when moving from dirty to clean areas.
MDS Did Not Accurately Reflect Condom Catheter Use
Penalty
Summary
The facility failed to ensure that Resident #39’s MDS assessments accurately reflected his status by incorrectly coding the presence of a condom (external) urinary catheter on 2 consecutive quarterly assessments. On the quarterly assessment dated 04/27/2026, Section H - Bowel & Bladder, subsection H0100 Appliances, was coded to show both an indwelling urinary catheter and an external urinary catheter. On the quarterly assessment dated 05/04/2026, Section H - Bowel & Bladder, subsection H0100 Appliances, was coded as “None of the Above.” Resident #39 was a [AGE] year-old male with diagnoses including flaccid hemiplegia affecting the left nondominant side, acute kidney failure, weakness, psychotic disorder, stroke, depression, anxiety, heart failure, and pain. His care plan dated 07/28/2025 identified that he required an external catheter (condom catheter) related to personal preference and dignity concerns. During observation on 07/14/2026, a urine collection bag was noted hanging under his bed frame in a privacy bag, and during interview the resident stated he wore a condom urinary catheter to keep his clothing and bed linens dry and needed staff assistance with changing it. The DON stated the resident used a condom catheter and that the MDS should have been coded to indicate the catheter.
Failure to Complete PASRR Follow-Up for Resident With Mental Illness
Penalty
Summary
The facility failed to refer a resident with newly evident or possible serious mental illness for PASRR evaluation and failed to follow up with the LA for a PASRR Level II determination after the resident’s PASRR Level I screening reflected a positive mental illness finding. The resident’s record showed diagnoses of bipolar disorder, major depressive disorder, morbid obesity, and post traumatic stress disorder, and physician orders included Depakote, Sertraline, Amantadine, Fluoxetine, Prazosin, and permission for psychiatric and psychological services as needed. The quarterly MDS documented the resident as cognitively intact with active diagnoses including seizure disorder or epilepsy, bipolar disorder, and post traumatic stress disorder. The resident’s care plan noted risk for adverse drug effects due to psychotropic medications used for depression, but there was no evidence in the care plan that the bipolar diagnosis was being addressed. During interview, the DON stated that all residents’ PASRR information was expected to be accurate and that if a resident had a diagnosis that could potentially qualify them for specialized services, the PE should be completed and sent to the LA. The DON stated the failure occurred due to human error and did not feel it affected the resident’s care. The facility policy stated that the purpose of PASRR is to identify residents with MI, ID, or DD/related conditions to ensure proper placement and receipt of needed services, and that the MDS coordinator or designee would input all other PL1s into the online portal on admission.
Care Plan Did Not Address Resident Smoking Status
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for Resident #55 that included measurable objectives and time frames to meet the resident's needs. Resident #55 was a [AGE]-year-old male admitted with diagnoses including stroke, right side paralysis, rheumatoid arthritis, schizophrenia, seizures, and blindness. His admission MDS assessment dated 06/23/2026 showed a BIMS score of 15 out of 15, indicating intact cognition, and Section J1300 indicated no current tobacco use was selected. During observation on 07/15/2026 at 10:38 a.m., Resident #55 was seen in the designated smoking area smoking a cigarette. Review of the resident's comprehensive care plan dated 06/18/2026 and revised 07/14/2026 showed tobacco use was not addressed. Staff interviews confirmed that the resident was a smoker and that smoking status should have been included on the care plan. The DON stated he was ultimately responsible for care plan accuracy and completeness, and the Administrator stated smoking status should be on the care plan, but it had been missed due to human error.
Unlocked Medication Cart Left Unattended
Penalty
Summary
The facility failed to store drugs and biologicals in locked compartments during a medication storage inspection for 1 of 3 medication carts reviewed, the West Hall Medication Cart. During an observation on 07/15/2026 at 12:43 p.m., the West Hall Medication Cart sitting by the entrance to the hallway was unlocked while unattended. Two residents were sitting in wheelchairs at the nurses' station near the cart, and no nurse was observed on the hall. The top drawer contained OTC medications including diphenhydramine and acetaminophen, as well as prescription antiemetic topical medication, prescription eye drops, and alcohol swabs. The next drawers contained gloves and prescription tablets in bubble packaging, prescription breathing treatments, liquid Maalox, over-the-counter topical cream, lancet sharps, insulin needles, and disinfecting wipes. A locked drawer contained narcotic medication. During interview, the DON stated the medication cart should be locked when a nurse was not present and that nurses were responsible for locking their own carts. LVN A stated the cart should be locked when not attended and said she had left it unlocked while helping a resident who fell. The facility policy stated medications and biologicals are to be stored in locked compartments and controlled substances are to be separately locked.
Menu Substitutions Not Communicated to Residents
Penalty
Summary
The facility failed to ensure the menu was followed for 3 of 18 residents reviewed for food and nutrition services. On 07/14/2026, the posted lunch menu in the dining room listed tortilla soup, soft beef taco, refried beans, shredded lettuce and chopped tomato, chocolate brownie, and beverage, but residents were served tomato soup instead of tortilla soup. The facility dietitian stated the menu should ideally be followed and that if a food item had to be substituted, residents should be notified of the substitution. Resident #5 was an older male with diagnoses including unspecified protein-calorie malnutrition and a Quarterly MDS showing a BIMS score of 12. During observation and interview in the dining room, he was served tomato soup rather than tortilla soup and stated he was not told the soup would be different. Resident #48, an older male with anemia and a Quarterly MDS showing a BIMS score of 06, was also observed in the dining room and was served tomato soup instead of the menu item. Resident #25 was an older male with type 2 diabetes mellitus and a Quarterly MDS showing a BIMS score of 15. During observation and interview, he received his lunch tray in his room with a ticket indicating tortilla soup, but he was served tomato soup instead. He stated he would not eat tomato soup because he does not like cooked vegetables and said he was not informed that he would not get tortilla soup. The DM stated there was a problem with the soup during lunch service, the remaining tortilla soup had to be disposed of, and she did not tell residents or nursing staff about the menu change.
QAPI Failure to Address RN Coverage Deficiency
Penalty
Summary
The facility’s QAPI committee failed to implement an appropriate action plan to address an identified quality deficiency related to RN coverage. A CMS 2567 dated 12/05/2025 cited deficient practice at F727 after interview and record review showed the facility failed to ensure the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 1 of 1 month reviewed for RN coverage, including 11/01/2025, 11/02/2025, 11/08/2025, 11/29/2025, and 11/30/2025. Record review of the facility’s Plan of Correction dated 9/5/2024 stated that the facility had hired a weekend RN, that the DON or designee would monitor the staffing schedule daily, and that the issue would be brought before the QAPI committee for the next two months. However, review of the PBJ Staffing Data Report for FY Quarter 2 2026 showed no RN hours reported to CMS on 1/03/2026, 1/24/2026, 1/25/2026, 1/31/2026, and 3/13/2026. During interview, the ADMN stated she could not provide evidence that an RN was working eight consecutive hours on those dates and said she would expect the plan of correction to be followed and reviewed during QAPI meetings to monitor whether the issue had been resolved.
Non‑measurable, non–person‑centered care plans for multiple residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for all six residents reviewed. The facility’s own policy, dated 03/2022, required comprehensive person-centered care plans that include measurable objectives and timetables to meet residents’ physical, psychosocial, and functional needs. However, record review showed that the care plans contained generic, non–person-centered objectives that could not be evaluated, quantified, or verified. The MDS Coordinator, Social Worker, and Administrator each acknowledged during interviews that the objectives in the care plans were not person-centered or measurable, and that the MDS Coordinator and IDT were responsible for ensuring that care plan objectives met these standards. For one resident with hypothyroidism, dementia, psychosis, migraines, metabolic encephalopathy, HTN, and asthma, the admission MDS showed intact cognition, yet the care plan objectives were broad and non-measurable across multiple identified problem areas. These included decreased functional abilities related to impaired cognition and mobility, resistance to care related to adjustment to the facility, impaired decision-making and rejection of necessary care related to dementia and encephalopathy, a wish to remain in the facility, risk for cardiac complications related to HLD, ASHD, and HTN, risk of adverse drug effects from psychotropic use and polypharmacy, risk for weight changes related to depression and new admission, risk for psychosocial decline related to new SNF placement, frequent pain related to migraines and impaired mobility, decreased visual acuity, and risk for respiratory distress related to asthma. Objectives such as "maintain current level of function," "cooperate with care," "maintain stable weight," and "remain free from complications" lacked specific, measurable criteria or timeframes. For another resident with COPD, polyneuropathy, recurrent UTI, AFib, nicotine dependence, MDD, quadriplegia, HTN, and generalized anxiety, the quarterly MDS showed intact cognition, but the care plan again used non-measurable objectives. These covered high fall risk related to quadriplegia and impaired mobility, GERD requiring management, increased infection risk related to chronic UTI and neuromuscular bladder, AFib and HTN requiring monitoring, total assistance needs for mobility and ADLs, long-term care needs due to complex conditions, COPD and respiratory failure with PRN oxygen, bladder/BPH with chronic UTIs, depression, anxiety, mood disorder, insomnia, ADL self-care deficits, verbal aggression and poor coping, a history of false accusations, and multiple medication-related risks (antidepressants, anticoagulants, anti-anxiety meds, diuretics, anticonvulsants, oxygen therapy, and SOB related to COPD). Objectives such as remaining free from falls, infection, or adverse drug reactions, maintaining stable cardiovascular status, and demonstrating effective coping skills were not individualized or measurable. A third resident with post-traumatic seizures, schizoaffective disorder, generalized anxiety, and schizophrenia had an admission MDS indicating inability to complete the BIMS interview, yet the care plan still lacked measurable, person-centered objectives. Problem areas included ADL self-care deficits related to mobility impairment, behavior problems and self-harm (yelling, refusing care, hitting self on objects, cursing, hitting hand on walls/doors/windows, attempting to pull a fire extinguisher), impaired thought processes related to schizophrenia, psychosis, and IDD, HTN, a prior fall with no injury related to poor communication/comprehension, antidepressant use for insomnia, anticonvulsant use for schizophrenia and psychosis, potential nutritional problems related to cognitive impairment, and potential psychosocial well-being problems related to recent admission. Objectives such as maintaining current ADL function, having fewer episodes of yelling or self-harm, being able to communicate basic needs daily, remaining free of HTN complications, and complying with diet were not defined in measurable terms. For a fourth resident with combined systolic and diastolic heart failure, MDD, acute respiratory failure, dementia, generalized anxiety, and GERD, the quarterly MDS showed moderate cognitive impairment, and the care plan had not been updated since a review several months earlier. The care plan listed difficulty making self-understood related to dementia, no plans to discharge, history of major depression and anxiety, risk for nutritional decline related to depression, DM, dysphagia, diuretic use, and GERD, impaired abilities related to weakness and impaired cognition, bowel and bladder incontinence related to impaired mobility and cognition, risk for pain related to diabetic neuropathy and chronic pain, potential adverse reactions to sulfa and tramadol, use of Lexapro for depression, and dietary needs. Objectives such as maintaining ability to make needs known, having care needs met daily and PRN, being free from signs of increased depression or anxiety, maintaining stable weight, maintaining or improving functional abilities, being clean and dry, functioning with minimal interference from pain, having no allergic reactions, being free from antidepressant side effects, and complying with diet were not written in measurable, person-centered terms. For a fifth resident with lung cancer, HTN, secondary malignant neoplasm of lymph nodes, and chronic systolic heart failure, the admission MDS showed intact cognition, but the care plan again used generic, non-measurable objectives. Identified issues included the need for staff supervision when using tobacco, HTN, wound management and a documented pressure ulcer, decreased functional abilities related to terminal lung and lymph cancer, CHF, anemia, risk for weight changes and aspiration related to terminal condition and dysphagia, chronic pain related to cancer, terminal prognosis, and risk for bowel and bladder incontinence related to terminal condition. Objectives such as following the tobacco policy without injury, maintaining blood pressure within normal limits, showing wound improvement, managing the pressure ulcer, maintaining current function, having clear lung sounds and normal heart rate/rhythm, remaining free of anemia complications, maintaining stable weight and being free from aspiration signs, avoiding discomfort from analgesia side effects, maintaining comfort, and remaining continent were not measurable or individualized. For a sixth resident admitted with a displaced fracture of the right femur lesser trochanter, the admission MDS did not include a completed cognitive section, and no BIMS score was determined. The care plan for this resident included wound management, but the objective "wound will show signs of improvement" was not defined in measurable terms. Across all six residents, the facility’s care plans did not include specific, quantifiable goals or clear timeframes, despite the facility’s policy requiring comprehensive, person-centered care plans with measurable objectives and timetables.
Failure to Obtain Required PASRR Level II Determination Prior to Preadmission
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required PASRR Level II evaluation and determination were completed prior to admitting a resident categorized as a Preadmission with suspected mental illness and intellectual disability. The resident was an adult male with an original admission date in late February and a most recent admission in early April, and his diagnoses included post-traumatic seizures, schizoaffective disorder, generalized anxiety, schizophrenia, and unspecified intellectual disabilities. His admission MDS showed a BIMS score of 99, indicating he was unable to complete the interview, and documented active diagnoses of post-traumatic seizures, unspecified intellectual disabilities, and schizophrenia. Record review of the resident’s PASRR Level I (PL1) screening, completed the day before his original admission, showed he was categorized as a Preadmission, with the referring entity identified as the Texas Department of Criminal Justice. The PL1 Section C indicated suspicion of both mental illness and intellectual disability, which required a PASRR Level II assessment and determination before admission. Despite this, the facility admitted the resident without having the PASRR Level II evaluation completed or a determination made. Interviews with facility staff revealed that during an ongoing CHOW process, the local LMHA/LIDDA had informed the facility that they could not proceed with PASRR processing in the TMHP LTC Online Portal due to the lack of a provider number, and therefore were not completing Level II PASRR assessments. The Regional Nurse Consultant acknowledged awareness that a PASRR Preadmission positive individual could not be admitted until after a Level II assessment and determination, while the Administrator stated he was unaware that Level II assessments were not being completed or that a PASRR-positive Preadmission resident had been admitted. The Marketing Director reported she ensured PL1 completion prior to admission but was unaware of the subsequent LMHA/LIDDA process, and the MDS Coordinator stated she was keeping a list of PL1-positive residents admitted during the CHOW and believed they could be admitted, despite also knowing that PASRR Preadmission residents with suspected mental illness or intellectual disability could not be admitted before completion of the Level II assessment and facility determination of ability to meet their needs.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, seven days a week, as required by regulation. Record review of the RN nursing schedule for November 2025 revealed that there was no evidence of 8-hour RN coverage on five specific days within the month. Both the Director of Nursing (DON) and the Administrator confirmed during interviews that there was no RN coverage on these dates. The DON stated that she could not cover every shift and acknowledged the lack of RN coverage on the identified days. The DON also indicated that the Assistant Director of Nursing (ADON) was responsible for completing the staffing schedule, while she monitored it. The Administrator, who started on the first day of the month, also confirmed the expectation for daily 8-hour RN coverage and stated that the DON was responsible for monitoring the schedule. The DON and Administrator both expressed that they did not believe there was a negative effect on residents due to the lack of RN coverage, citing staff access to the DON and communication channels such as a group chat with corporate staff. The DON attributed the failure to difficulties in hiring RNs willing to work with the facility's specific resident population, which included individuals from the penal system and/or sex offenders. The Administrator stated that the facility did not have a specific policy but followed federal and state regulations. There was no mention of any specific resident being directly affected or any adverse outcomes resulting from the deficiency.
Failure to Serve Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature during a lunch meal. Observations revealed that the posted menu included pork steak with gravy, black-eyed peas, cauliflower with cheese, a roll, and banana cake. Staff interviews indicated that residents had complained about cold food. The cook reported taking the temperature of the pork chop at 155 degrees before serving, but left plated food uncovered on the counter for 2-3 minutes. The dietary manager (DM) observed that the pork chop was only 80 degrees when checked later, and the food was not warm to the touch. The DM also noted that the roll was overcooked, the gravy was too thin, the cake was not iced, and mechanical soft meat was incorrectly placed on the vegetables. The DM expressed embarrassment over the food service and stated that the cook did not follow recipes or facility policies. A resident commented that the food looked unappetizing and left the meal uneaten. The DM and administrator both confirmed that the cook was responsible for ensuring food was cooked and served at the correct temperature, and that the DM was ultimately responsible. Review of facility policy confirmed that food and nutrition staff are required to ensure food is palatable, attractive, and served at a safe and appetizing temperature. Temperature logs showed the pork chop was 180 degrees when removed from the oven and 155 degrees at the start of service, but food was not maintained at appropriate temperatures during plating and serving.
Neglect Leads to Wound Infestation in Resident
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, leading to a serious deficiency. The resident, who had a history of chronic obstructive pulmonary disease, dementia, spinal stenosis, hypertension, and dysphagia, suffered a skin tear on his right elbow after a fall. Despite the injury occurring on 05/17/2024 and reopening on 05/25/2024, the facility did not obtain treatment orders or provide wound care until 06/02/2024. This neglect resulted in the wound becoming infested with maggots, which were discovered by the resident's family member on 06/01/2024. The resident's family member had a video camera in the room and observed the resident fall on 05/17/2024, which led to a head injury and a skin tear. The family member reported the fall to the facility and later discovered the wound's poor condition, including maggots, on 06/01/2024. Despite the family member's intervention and notification to the nursing staff, the facility failed to provide timely wound care or notify the physician until days later. The lack of documentation and communication among the nursing staff further exacerbated the situation, as several nurses were unaware of the wound care needs or the presence of maggots until it was too late. Interviews with the facility's staff revealed a lack of awareness and communication regarding the resident's condition and necessary wound care. The Director of Nursing (DON) and other staff members admitted to not having clear documentation or communication about the resident's discharge orders from the emergency room. The facility's failure to follow up on the resident's condition and ensure proper wound care led to the identification of an Immediate Jeopardy situation, highlighting significant lapses in the facility's care and oversight processes.
Neglect in Wound Care Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident who sustained a skin tear on their right elbow. The resident initially obtained the skin tear on May 17, 2024, which reopened on May 25, 2024. Despite the reopening of the wound, the facility did not obtain treatment orders or provide wound care until June 2, 2024. During this period, the resident's family member discovered maggots in the wound on June 1, 2024, indicating a severe lapse in care and hygiene. The resident, who had a history of chronic obstructive pulmonary disease, dementia, spinal stenosis, hypertension, and dysphagia, was admitted to the facility with intact cognitive response and moderate hearing difficulty. After the initial fall and skin tear, the resident was sent to the emergency room and returned with a bandage on the wound. However, the facility failed to follow up with appropriate wound care orders or ensure the wound was properly managed, leading to the infestation of maggots. Interviews with staff revealed a lack of communication and follow-up on the resident's condition. The nursing staff did not have clear orders for wound care, and there was confusion about the responsibility for monitoring and treating the wound. The Director of Nursing acknowledged the failure to implement wound care orders promptly, and the facility's neglect in addressing the resident's wound care needs resulted in an Immediate Jeopardy situation.
Failure to Maintain Accurate Medical Records and Provide Wound Care
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, leading to a significant deficiency in care. The resident, who had a history of chronic obstructive pulmonary disease, dementia, spinal stenosis, hypertension, and dysphagia, returned from an emergency room visit with a bandaged right elbow. However, the facility did not document the presence of the bandage or provide appropriate wound care instructions upon the resident's return. This oversight resulted in the resident's wound becoming infested with maggots, as discovered by a nurse and the resident's family member. The resident's medical records lacked documentation of wound care from the time of the emergency room discharge until the discovery of the maggots. The nurse who found the maggots reported that the bandage was saturated with drainage and blood, indicating a lack of proper wound management. The resident's family member also observed the maggots and reported the issue to the facility staff, who were unable to provide immediate care due to staffing shortages. The family member had to clean and bandage the wound herself. Interviews with facility staff, including the Director of Nursing, revealed that there were no orders for wound care until several days after the resident's return from the emergency room. The facility's policy on charting and documentation was not followed, as there was no clear communication or documentation regarding the resident's condition and the necessary care. This failure to adhere to professional standards and practices in maintaining medical records and providing timely wound care led to the deficiency.
Deficiencies in Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which resulted in deficiencies in addressing their specific needs. For one resident, the care plan did not include the current code status of Do Not Resuscitate (DNR), despite this being documented in the physician orders. The care plan's section on code status was incomplete, lacking the necessary details to ensure that the resident's wishes were communicated and honored by the facility staff. This oversight was acknowledged by the Director of Nursing (DON), who admitted that the code status should have been incorporated into the care plan. For another resident, the care plan failed to address the conditions of probation, which included notifying the probation officer if the resident left the facility and restrictions on access to internet-capable electronic devices. The probation officer confirmed these stipulations during an interview, and the Clinical Resource Nurse and DON both expressed that such information should have been included in the care plan. Additionally, the care plan did not provide measurable approaches or frequency for addressing the resident's wounds on both lower legs. The facility's policy on comprehensive care plans emphasizes the need for measurable objectives and timeframes, which were not met in these cases.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, seven days a week, on specific dates within a 90-day review period. This deficiency was identified on eight occasions: 10/07/2023, 10/08/2023, 10/21/2023, 10/22/2023, 10/28/2023, 10/29/2023, 11/04/2023, and 11/05/2023. The absence of RN coverage on these dates was confirmed through a review of the facility's Direct Care Staff Daily Report. Interviews with the Director of Nursing (DON) and the Administrator (ADMN) revealed that the lack of RN coverage was an inherited issue, particularly on weekends, and was attributed to difficulties in hiring due to the facility's location. The facility's policy, dated 09/28/2023, mandates RN coverage for 8 consecutive hours daily, which was not adhered to, placing residents at risk for inadequate healthcare management and oversight of direct care staff.
Failure to Follow Pureed Diet Menu
Penalty
Summary
The facility failed to adhere to the prescribed menu for residents on a pureed diet, specifically omitting a pureed roll from the meal. This deficiency was observed during a lunch meal where three residents, all on mechanically altered diets, did not receive the pureed roll as indicated on their meal tickets. The residents involved had various medical conditions, including hypertension, depression, diabetes, aphasia, cerebrovascular accident, dementia, and malnutrition, which necessitated a mechanically altered diet. During observations, it was noted that the kitchen staff did not include the roll in the pureed items prepared for the residents. Interviews with the dietician and dietary manager revealed that the expectation was for all menu items, including the roll, to be provided to residents on a pureed diet. The dietician emphasized the importance of following the menu to ensure residents receive all food groups and necessary calories, while the dietary manager acknowledged the oversight and attributed it to kitchen staff being nervous. The administrator also confirmed the expectation for all residents to receive all menu items, including the roll, and recognized the potential impact of not doing so, such as weight loss. Despite the monitoring systems in place, including checks by nurses and dietary staff, the omission occurred, and the reason for not offering the pureed roll remained unclear. The facility's policy on menu planning underscores the importance of providing a well-balanced and nutritious menu that meets residents' preferences and nutritional needs.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by improper storage, preparation, distribution, and serving of food in the kitchen. Observations revealed that food items in the refrigerator were not sealed or labeled correctly, with a plastic container of sliced cheese and chicken noodle soup not properly covered. Additionally, a container of chopped onion lacked a label identifying the item and date. In the dry storage area, packages of coconut flakes were not labeled with an item description and showed signs of pink discoloration, while cans of evaporated milk were past their best-by date. The facility also failed to ensure proper thawing and temperature control of food items. Hamburger meat was observed thawing in an aluminum pan with half of the package not submerged in water, contrary to proper thawing procedures. During meal preparation, pureed chicken fried chicken was made using cold milk, and its temperature was not taken before being placed in the steam table. The temperature of the pureed chicken was later found to be below the required level, necessitating reheating in a microwave. Furthermore, the thermometer used to check food temperatures was not sanitized between uses, increasing the risk of cross-contamination. Interviews with staff, including the Dietician and Dietary Manager (DM), highlighted a lack of adherence to facility policies and procedures for food storage and preparation. The Dietician and DM expressed expectations for proper labeling, sealing, and discarding of expired food items, as well as correct thawing and temperature monitoring practices. However, they acknowledged that these standards were not consistently met, potentially due to insufficient staff education and monitoring. The Administrator also noted that the failure to sanitize the thermometer and take appropriate temperatures was partly due to the inexperience of a new dietary aide.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to accommodate the needs and preferences of two residents by not ensuring their call lights were within reach, which is a requirement outlined in their care plans. Resident #13, a male with flaccid hemiplegia, sepsis, aphasia, and dysphagia, was observed on multiple occasions with his call light placed on the nightstand, out of his reach. Despite being dependent on staff for mobility and having impaired communication abilities, the call light was not positioned where he could access it using his left arm, as he was unable to use his right arm. A CNA acknowledged that the call light should have been attached to his pillow for accessibility. Similarly, Resident #14, a female with cervical disc degeneration and severe cognitive impairment, was found unable to reach her call light, which was placed on top of an oxygen concentrator, obstructed by a nightstand. This resident, who also required staff assistance for mobility, expressed difficulty in reaching the call light. A CNA admitted to leaving the call light out of reach after providing care earlier in the day. The DON confirmed that both residents could not exit their beds without assistance and acknowledged the oversight in ensuring the call lights were accessible, which could potentially delay care.
Failure to Properly Execute Advance Directives
Penalty
Summary
The facility failed to ensure the proper execution of advance directives for two residents, specifically regarding the Out of Hospital Do Not Resuscitate (OOH-DNR) orders. Resident #42, a male with moderate cognitive impairment and a diagnosis of unspecified psychosis, had a code status of Do Not Resuscitate. However, his physician orders did not include a DNR order, and his OOH-DNR form lacked the required two witness signatures. Similarly, Resident #48, a male with multiple health conditions including hypertension and kidney failure, also had a DNR code status. His physician orders similarly lacked a DNR order, and his OOH-DNR form was missing the necessary witness signatures. Interviews with facility staff revealed a lack of understanding and adherence to the requirements for completing OOH-DNR orders. The social worker (SW) responsible for ensuring the completion of DNRs was not up to date with the current rules, mistakenly believing that witness signatures were not needed if a family member signed the form. The Director of Nursing (DON) acknowledged that the SW was responsible for completing the OOH-DNRs correctly and attributed the failure to a lack of education. The facility's policy on advance directives emphasized the importance of documenting a resident's code status and ensuring that all necessary signatures were obtained for OOH-DNR orders. The policy also required that the attending physician be informed of any changes to a resident's code status. The report highlighted that the failure to properly execute these directives could result in residents receiving treatments that contradict their personal preferences.
Failure to Provide Comprehensive Discharge Summary
Penalty
Summary
The facility failed to ensure that a resident had a comprehensive discharge summary, including a recapitulation of the resident's stay, medication reconciliation, and a discharge plan of care. This deficiency was identified for one resident who was reviewed for discharge summaries. The resident, a male with diagnoses including bacterial infection, heart failure, dementia, and kidney disease, was discharged home without the necessary documentation and planning. The review of the resident's records revealed several omissions. There was no evidence of a discharge plan with defined goals and interventions, nor was there a care plan conference with the resident or family member. Additionally, there was no discharge order in the electronic physician's orders, and the electronic record lacked discharge paperwork, including an evaluation of the resident's discharge needs, a discharge summary, or a post-discharge plan. Interviews with facility staff highlighted a lack of clarity and responsibility in the discharge process. The LVN involved could not recall the specifics of the discharge and stated that her training only involved completing a discharge progress note and printing a list of medications. The DON acknowledged that a discharge summary should have been completed and accepted responsibility for the oversight. The social worker indicated minimal involvement in the discharge process and could not recall details related to the resident's discharge. The facility's policy required a comprehensive discharge summary and post-discharge plan, which were not adhered to in this case.
Deficiency in Resident Room Certification and Readiness
Penalty
Summary
The facility failed to ensure that certain resident rooms were certified and equipped for adequate nursing care, comfort, and privacy. Specifically, rooms #45 and #46, which were certified for two Title 18 resident beds each, were not resident-ready as they had been converted into a large activities room by removing the shared wall. Similarly, rooms #47, #48, and #49 were combined into a theater room, and rooms #52 and #53 were turned into a therapy room, with their shared walls removed. These modifications rendered the rooms unsuitable for immediate transition back to resident-ready status. During an interview, the facility's administrator admitted to not having a reason for why the beds were not decertified and acknowledged a lack of policy regarding bed class/certification. The administrator, who had been in the position for over a year and a half, stated that the rooms had been set up in their current configurations since her tenure began and had not considered the need for decertification. The facility's Bed Classification Form and CMS-671 confirmed that these rooms were still certified for resident beds, despite their current use for non-residential purposes.
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Illustrative
What surveyors actually found near you
We read the 144 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Granbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Granbury Care Center | 1.2 mi | ★★★★★ | 13 | 0 |
| Harbor Lakes Nursing And Rehabilitation Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Granbury Rehab & Nursing | 2.8 mi | ★★★★★ | 14 | 0 |
| Glen Rose Nursing And Rehab Center | 14.7 mi | ★★★★★ | 10 | 0 |
| Cherokee Rose Nursing & Rehabilitation | 15.2 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.