Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Granbury Care Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including DM, peripheral vascular disease, a right BKA, a stage 4 pressure ulcer, and a PICC line for IV therapy, was admitted and had detailed nursing notes and a comprehensive care plan initiated, but the admission MDS assessment was not completed within the required 14-day timeframe and did not trigger any CAAs. The facility’s Resident Matrix did not reflect the resident’s IV therapy because it relied on the incomplete MDS. The MDS nurse acknowledged being behind on assessments, and leadership confirmed that MDS coordinators were responsible for timely comprehensive assessments per facility policy, but there was no active monitoring process in place to ensure completion.
A resident with type 2 DM and multiple comorbidities had a physician order for Lantus 10 units SQ daily with instructions to hold the dose if blood glucose was less than 120. Over a two‑month period, several LVNs and the ADON documented administering Lantus despite blood glucose readings below the ordered hold parameter, with values in the 80s to high teens. Staff confirmed that check marks on the MAR indicated the insulin was given, and interviews with an LVN, the DON, and the physician established that the order required holding insulin when blood glucose was below the specified threshold and that nurses were expected to follow updated orders.
Food service staff failed to properly label and date multiple kitchen items, including bruised bananas, dented cans, opened bottles, and numerous dry goods and gelatin mixes without received, expiration, or use-by dates. Interviews showed staff were responsible for dating deliveries and opened items, and the DM was responsible for monitoring dates, but the kitchen observation found many items missing required labels and dates.
A resident with diabetes and severe cognitive impairment received insulin glargine twice daily, but the MAR showed multiple held doses without corresponding progress notes explaining why the medication was withheld or documenting physician notification. The physician order did not include a hold parameter for FSBS under 70, even though the physician stated that was his expectation. An LPN said she believed the EMR would generate a note automatically when she used a hold code, while the DON stated staff were expected to notify the physician right away and document the communication.
The facility failed to complete regular inspections of bed frames, mattresses, and bed rails for three residents. One resident with paraplegia used bilateral assist rails for bed mobility, another resident with dementia had a loose mobility bar that moved when pushed, and a third resident with dementia, a prior femur fracture, and pain used bed rails on both sides of the bed. The DON, Maint D, ADMN, and SW-B stated there was no effective system for assessing bed rails, and the facility's Bed Rail Assessments showed no evidence of regular inspection and maintenance.
Failure to obtain written consent for antipsychotic medication: A cognitively intact resident with bipolar disorder received risperidone without documented HHSC Form 3713 consent before the initial dose and again after the dose was increased. The resident’s representative said she had been informed of the changes but had not signed the required form, while the ADON-A and DON acknowledged consent should have been obtained before administration.
PRN psychotropic orders were left active beyond the 14-day limit for two residents without a documented rationale from the prescriber. One resident had a PRN lorazepam order for combative/anxiety with no stop date and no doses given, while another resident had PRN diazepam gel and sublingual suspension orders for anxiety/agitation with no stop date and limited administration. Staff interviews showed the nurse entering the order was expected to add the stop date and the DON was expected to monitor stop dates, and the facility policy required PRN psychotropic orders to be limited to 14 days.
Missing Informed Consent for Bed Rail Use: A resident with dementia and Alzheimer's disease, moderate cognitive impairment, and assistance needs for transfers had a mobility bar installed on her bed without evidence of informed consent from her or her representative. Surveyors observed the bar in use and noted it was loose; the DON stated consent was expected before installation and should include the risks and benefits, while the ADON-A and ADMN could not explain why consent had not been obtained.
A resident with multiple sclerosis and moderate cognitive impairment was observed with 9 medications left in a pill cup on her bedside table while lying in bed. The MA stated she handed the meds to the resident but did not verify they were all taken before leaving the room. The DON stated meds should not be left at the bedside and staff should ensure all medications are consumed before exiting.
A resident with full code status and under hospice care was not provided CPR by an LVN when found unresponsive, despite clear physician orders and care plan documentation. The LVN, distracted by a personal emergency and mistakenly assuming hospice patients had DNR orders, failed to initiate CPR or contact EMS, and instead directed post-mortem care. This action was inconsistent with facility policy and the resident's documented wishes.
A deficiency was cited when a resident's care plan did not address all identified needs and failed to include measurable timetables or specific actions, as observed in the resident's records and care documentation.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
The facility did not document weekly skin assessments for three residents at risk for pressure ulcers, including one with stage 4 wounds and others requiring extensive assistance, despite staff performing skin checks and completing shower sheets. Nursing staff cited changes in the electronic medical record system and competing duties as reasons for missed documentation, though assessments were reportedly performed.
Two residents with cognitive and behavioral health issues were left unsupervised while waiting for a scheduled smoke break, leading to an altercation between them. Staff were frequently late to supervise smoke breaks, especially on weekends, and the posted schedule was not consistently followed. The lack of timely supervision resulted in resident agitation and physical contact, as confirmed by interviews, observations, and record reviews.
A CNA failed to follow proper infection control practices during incontinence care for a resident with Alzheimer's disease, not changing gloves or performing hand hygiene after handling a soiled brief. The CNA acknowledged the mistake, despite recent infection control training. The facility's policy requires hand hygiene and glove changes, which were not followed.
The facility failed to obtain written consent for antipsychotic medications for two residents, leading to a deficiency. One resident with moderate cognitive impairment was given Ziprasidone without a signed consent form, while another with severe cognitive impairment received Seroquel without consent documentation. The DON acknowledged the oversight, attributing it to staff turnover and lack of monitoring. Facility policy requires written consent before administering psychotropic drugs, which was not adhered to in these cases.
A facility failed to refer a resident for a PASRR screening despite the resident's significant history of mental illness, including Bipolar disorder, anxiety, and PTSD. The resident was admitted with a negative PL1, and the necessary re-evaluation was not conducted until an internal audit revealed the oversight. Staff interviews indicated a lack of familiarity with required procedures and forms, and the facility's policy did not adequately address the steps needed for such cases.
The facility failed to properly label and store medications, including expired drugs on a medication cart and missing pharmacy labels on insulin pens for two residents with diabetes. Additionally, controlled substances lacked count sheets in a medication room, risking undetected shortages. Staff interviews revealed lapses in protocol adherence, and pharmacy representatives emphasized the importance of proper labeling and disposal.
The facility failed to provide food and drink at a safe and appetizing temperature, affecting several residents. Concerns were raised about cold, flavorless food, and lack of condiments. A test tray confirmed food temperatures were below acceptable levels, contrary to the facility's policy.
The facility failed to maintain food safety and hygiene standards in the kitchen, with staff not wearing effective hair restraints and neglecting proper hand hygiene. Observations included staff handling food and utensils without gloves, not washing hands between tasks, and handling silverware improperly. Interviews revealed a lack of adherence to infection control policies, with staff acknowledging their lapses and the potential for cross-contamination.
A resident with severe cognitive impairment and multiple medical conditions did not have a comprehensive care plan addressing his edema and refusal of care. Despite physician orders for compression stockings and leg elevation, these were not included in the care plan. The Interim DON cited being new to the role as a reason for the oversight.
A resident with severe cognitive impairment and multiple medical conditions had several unstageable pressure areas and a deep tissue pressure injury that were not present upon admission. An LVN inaccurately documented the resident's skin as intact, failing to adhere to the facility's policy for complete and accurate documentation. The RN was unaware of the reason for the inaccurate documentation, and the administrator stressed the importance of accurate reporting to prevent worsening conditions.
A resident with severe cognitive impairments was transported to a hospital via ambulance due to a change in condition, but the facility failed to notify the resident's POA and family promptly. The responsible nurse did not follow protocol, resulting in the family being informed by the hospital hours later, missing the opportunity to be with the resident during a critical time. Interviews with staff highlighted the importance of immediate family notification for resident comfort and advocacy.
A resident with severe cognitive impairment was transported to the hospital due to a change in condition, but the responsible party was not notified as documented. RN C falsely recorded that the family was informed, which was later admitted. The facility's policy on accurate documentation was not followed, leading to potential miscommunication and anxiety for the resident and family.
The facility failed to maintain functional call light systems for two residents with cognitive impairments, compromising their ability to alert staff for assistance. Observations showed that the call light strings were too short to be reached by residents, and staff were unaware of the issue until it was reported.
A CNA improperly transferred a resident using a Hoyer Lift without the required two-person assistance, leading to the resident hitting his head. Despite being trained, the CNA proceeded alone due to the absence of other aides and the resident's insistence on being transferred quickly. The facility's policies and the resident's care plan specified the need for two-person assistance.
Failure to Complete Timely Comprehensive Admission MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a comprehensive admission MDS assessment within 14 days of admission for one resident. Record review showed that this resident, a male with multiple diagnoses including a non-pressure chronic ulcer of the left heel, DM type 2, hyperlipidemia, insomnia, cellulitis of the left lower limb, peripheral vascular disease, a right below-knee amputation, and hypothyroidism, was admitted on a specified date. His admission MDS assessment, dated later in the month, showed no evidence that it was completed and no Care Area Assessments (CAAs) were triggered, despite the facility’s policy requiring a comprehensive assessment within 14 days of admission. Nursing documentation from the admission date described the resident as having a PICC line in the right upper arm, bowel and bladder incontinence, a right below-knee amputation, requiring two-person assistance with bed mobility and toileting, a mechanical lift for transfers, one-person assistance with dressing, hygiene, and bathing, supervision with eating and drinking, and the use of upper and lower dentures. The care plan initiated on the admission date included care areas and interventions for evidence-based practice, peripheral vascular disease, DM, incontinence, osteomyelitis, IV access, ADL self-care deficit, oral/dental health problems, and pressure ulcer care. A facility Resident Matrix later listed the resident as having a stage 4 pressure ulcer and being admitted on the same date, but did not reflect that he was receiving IV therapy, and there was no evidence in that document that he was receiving medication for diabetes, had an infection, or was on IV therapy. During observations and interviews, the resident was seen in bed with an IV pole, an IV access site in the right upper arm with an intact dressing, and a wound vac on the left heel with an intact dressing. He reported receiving IV medication for infection and care for his IV access and wound vac. The DON stated that the resident was on IV therapy and that the Matrix did not list IV therapy because it pulled from the MDS, which had not triggered IV therapy due to the incomplete assessment. The MDS Coordinator responsible for the admission assessment acknowledged that it had not been completed because she was behind on assessments and stated that the admission MDS should have been completed by a specific date. Facility leadership interviews confirmed that MDS Coordinators were responsible for completing comprehensive assessments, that there was no active monitoring process by the DON for timely completion, and that the facility policy required comprehensive assessments within 14 days of admission, with results used to develop, review, and revise the comprehensive plan of care.
Insulin Administered Contrary to Ordered Blood Glucose Parameters
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure residents were free from significant medication errors, specifically involving the administration of insulin contrary to physician orders. One male resident with multiple diagnoses, including dementia, mild cognitive impairment, morbid obesity, schizophrenia, essential hypertension, type 2 diabetes, and acute kidney failure, had a physician order for Lantus SoloStar (insulin glargine) 10 units subcutaneously once daily with a clear parameter to hold the dose if blood glucose was less than 120. His comprehensive care plan for diabetes included goals to prevent signs and symptoms of hyperglycemia and hypoglycemia and to avoid complications related to diabetes, with an intervention to administer diabetes medication as ordered by the physician and monitor for side effects and effectiveness. Review of the resident’s electronic MAR for a two‑month period showed that multiple nurses, including LVNs and the ADON, documented administering Lantus even when the resident’s blood glucose readings were below the ordered hold parameter of 120. Specific documented administrations included doses given when blood glucose values ranged from 84 to 118, on numerous dates across January and February, by several different licensed nurses. Each of these administrations was recorded with a check mark on the MAR, which staff confirmed indicated that the medication had been given. In interviews, one LVN stated that if a blood sugar was below the parameter, she would be expected to hold the insulin and that there would be no reason to give insulin outside the ordered parameters, acknowledging that doing so could cause the resident’s blood sugar to “bottom out.” She also stated she believed the order previously did not have parameters and was unsure when it changed. The DON confirmed that the Lantus order included a parameter to hold if blood glucose was less than 120 and that a check mark on the MAR meant the medication was administered. The DON stated that if blood sugar was below the parameter, the insulin should be held and that nurses should be aware of order changes discussed in the 24‑hour report and IDT meetings. The attending physician stated that if the resident’s blood sugar was under the parameter, nurses should not administer the Lantus and that all nurses were expected to follow his orders. The facility’s policy on physician orders required nurses to review orders, clarify them as needed, and ensure they were accurately entered and directed to the appropriate electronic administration record.
Food Items Not Properly Labeled in Kitchen
Penalty
Summary
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. During an observation of the kitchen on 02/16/2026 between 9:02 AM and 9:24 AM, surveyors found 2 boxes of bananas in the walk-in refrigerator that appeared brown and/or bruised and were not labeled with a received date or use by date. The same observation identified multiple food items that were either dented, opened without dating, or otherwise not labeled with required dates. These included dented cans of Frutas Tropicals, Banana Pudding, and Blueberry Topping; opened bottles of Chocolate Syrup, Liquid Smoke, and Worcestershire Sauce without received or expiration/use by dates; bags of white cake mix, cornbread mix, and multiple gelatin mixes without received or expiration/use by dates; 4 cans of Tomato Soup without received or use by dates; and a squeeze bottle containing an orange-colored liquid with no label and no received or expiration/use by date. Two bags of pecans had handwritten dates, and one bag of Lime Gelatin Mix had a handwritten date of 1/18/26 and a use by date of 1/24/26. During interviews, DA-F stated staff were responsible for putting up grocery deliveries and marking items with the date delivered and use by date once opened. DA-G stated all food items were marked with received date and use by date when opened, and that the DM was responsible for monitoring expiration or use by dates and removing out-of-date items. On 02/19/2026, DA-F stated she had received training on labeling and storage when hired, and the DM stated all kitchen staff were responsible for dating food items when delivered and that she monitored dates and discarded out-of-date items. Record review of the facility policy stated items without manufacturer expiration dates should be dated when received, and perishable refrigerated items should be dated once opened and used within 7 days if they do not have an expiration or best by/use by date.
Incomplete insulin hold documentation and missing order parameters
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for one resident with diabetes who had severe cognitive impairment and was receiving insulin glargine 14 units subcutaneously twice daily. The resident’s electronic physician orders dated 09/24/2025 did not include a parameter from the primary physician to hold insulin if FSBS was less than 70, even though the physician later stated that was his expectation. The resident’s care plan addressed diabetes and directed staff to administer diabetes medication as ordered and monitor for side effects and effectiveness. The resident’s MAR for January and February 2026 showed multiple held doses of insulin glargine, including entries coded as “other / see nurses notes,” “BS within normal limits no admin required,” “drug refused,” and “hold / see nurses notes.” However, the record review found no progress notes documenting why the insulin was not administered or documenting physician notification for the held doses on multiple dates. The only documented physician communication found was on 02/18/2026, when an LVN sent a message to the physician about holding the morning glargine dose because the FSBS ran off and asked whether a hold order could be written for FSBS under what level. During interview, the LVN stated she did not administer the insulin that morning, believed the system would automatically generate a note when she used code 9, and said she usually contacted the physician at the end of her shift unless it was an emergency. She also stated she could not find documentation of prior conversations with the physician about holding the insulin. The DON stated nurses were expected to notify the physician right away when a medication was held and that communication should be documented in the EMR. The physician stated he expected insulin glargine to be held if FSBS was less than 70 and that the order should have included that parameter, but he could not recall exactly when or how many times he had been notified about the resident’s blood sugars and holding of the insulin.
Failure to Inspect Bed Rails and Bed Equipment
Penalty
Summary
The facility failed to ensure regular inspections were conducted of bed frames, mattresses, and bed rails to identify possible entrapment hazards for 3 residents. The facility policy titled Bed Rails stated that all bed frames, mattresses, and bed rails, if any, were to be regularly inspected as part of a maintenance program to identify areas of possible entrapment and to ensure rails were installed according to manufacturer recommendations. The report identified that no evidence of regular inspections and maintenance was documented for Resident #7, Resident #22, and Resident #48. Resident #7 was a female with paraplegia, a history of falling, and muscle spasm. Her quarterly MDS reflected moderate cognitive impairment and she needed substantial to maximal assistance with bed mobility. Her care plan and physician orders reflected use of bilateral assist rails to promote safety with turning, repositioning, transferring, and bed mobility. During observation, she was in bed with rails up on both sides and stated she used them to help staff turn her. The facility's Bed Rail Assessment for her showed no evidence that regular inspections and maintenance had been completed. Resident #22 had dementia and Alzheimer's disease, with a quarterly MDS showing moderate cognitive impairment and need for assistance with bed mobility and transfers. Her care plan reflected a prior fall and use of a hand assist bar for transfers. No physician order for bed rails was found, yet during observation her bed had a mobility bar on the right side that was loose and moved about one inch when pushed. She stated she used the bar to get out of bed and did not know how long it had been loose. Resident #48 had dementia, a left femur fracture, obesity, and pain, with a BIMS score of 15 and need for setup assistance with bed mobility and supervision for transfers. His care plan and physician orders reflected use of 1/8 rails on both sides of the bed, and observation showed bed rails on both sides. His Bed Rail Assessment also showed no evidence that regular inspections and maintenance had been completed. Interviews with the DON, Maint D, ADMN, and SW-B showed there was no system in place for assessing bed rails, no completed assessments for the residents, and staff were not consistently checking whether the rails were tight or properly maintained.
Failure to Obtain Written Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure a resident had the right to be informed of and participate in treatment decisions, including being informed in advance of the risks and benefits of proposed care and treatment alternatives, for Resident #8. Resident #8 was a cognitively intact female with bipolar disorder and was receiving a high-risk antipsychotic medication. Her care plan reflected that she required antipsychotic medication and that the resident, family, or caregivers were to be educated about the risks, benefits, and side effects. Record review showed Resident #8 was started on risperidone 1 mg in the morning and 2 mg in the evening, and later the dose was increased to 2 mg twice daily. The chart contained no evidence that Resident #8 or her representative signed HHSC Form 3713 consenting to risperidone before the medication was first administered, and no evidence that they agreed to the dosage increase before the new dose was given. The MAR showed the medication was administered beginning with the initial order and continued after the dose increase. During interviews, the resident’s representative stated she had been informed about the medication changes and the increase in dosage, but she had not signed a form acknowledging the risks and said she would sign the next time she came to the facility. The ADON-A stated she was responsible for obtaining the signed HHSC Form 3713 before administration and acknowledged that a new consent should be obtained when the dosage changed. The DON stated antipsychotic consents should have been obtained before administration and that the psychiatric physician entered the order without notifying her or the ADON-A of the change. Facility policy required documented written consent prior to administration of a newly ordered psychotropic medication and stated phone or verbal consent was not allowed.
PRN Psychotropic Orders Exceeded 14 Days Without Documented Rationale
Penalty
Summary
The facility failed to ensure PRN orders for psychotropic medications were limited to 14 days or that a physician documented a rationale for extending the orders beyond 14 days for two residents reviewed for unnecessary medications. One resident, an older female with dementia, anxiety, and abnormal weight loss, had a PRN lorazepam order for combative/anxiety with a start date of 10/17/2025 and no stop date listed. Review of her MARs from November 2025 through 02/18/2026 showed no doses were administered, and the physician progress notes contained no documented rationale for continuing the PRN lorazepam beyond 14 days. A second resident, an older male with dementia and COPD, had PRN diazepam orders for anxiety/agitation in both gel and sublingual suspension forms, with start dates of 06/03/2025 and no stop date noted. Review of the MARs showed one dose of diazepam suspension in December 2025, one dose of diazepam suspension and two doses of diazepam gel in January 2026, and no doses of either form through 02/18/2026. The physician progress notes contained no documented rationale for ordering PRN diazepam for more than 14 days. During interviews, an RN stated the nurse receiving the order was responsible for entering a 14-day stop date and that the DON was responsible for monitoring stop dates. The DON stated the nurse receiving the PRN psychotropic order was responsible for ensuring a stop date was entered and that staff monitoring of order accuracy, including stop dates, was done by nursing staff. The facility policy titled Psychotropic Drugs stated PRN orders for psychotropic drugs and antipsychotic drugs must be limited to 14 days.
Missing Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to review the risks and benefits of bed rails with Resident #22 or her representative and failed to obtain informed consent before a mobility bar was installed on her bed. Resident #22 was an [AGE] year-old female with diagnoses including dementia and Alzheimer's disease, and her quarterly MDS reflected a BIMS score of 12, indicating moderate cognitive impairment. Her care plan noted a prior fall, use of a walker, need for supervision or touching assistance with bed mobility and transfers, and assistance x1 for transfers. The electronic physician orders reviewed for her contained no order for bed rail use, and the electronic record contained no evidence of informed consent for the mobility bar. During observation, Resident #22 had a mobility bar on the right side of her bed, and the bar was loose and moved approximately one inch when pushed. Resident #22 stated she used the bar to get out of bed and did not know whether she had told anyone it was loose. The DON stated she expected all residents using mobility bars to have informed consent prior to installation and said the consent should inform residents and representatives of the risks and benefits. The ADON-A stated she was not responsible for obtaining such consents and did not know who was responsible, and the ADMN stated the consent should have been obtained before the bed rails were utilized. The facility policy stated that the resident and/or resident representative would provide consent for the use of rails prior to installation.
Medications Left Unattended at Bedside
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional principles and state and federal requirements for one resident. Resident #25, a female with diagnoses including multiple sclerosis and knee pain, had a quarterly MDS showing a BIMS score of 11, indicating moderate cognitive impairment, and was receiving multiple medications including antidepressant, opioid-related, and other high-risk medications. On 02/16/2026 at 09:35 a.m., Resident #25 was observed lying in bed with 9 medications in a pill cup on her bedside table. During the observation, the resident stated she did not want to get anyone in trouble and said the medication aide usually did not leave medications on her table in a cup. She stated the medication aide knew she would take them, but would not identify the staff member who passed medications that morning. During interview, MA-D stated she had handed the medications to Resident #25 in a cup, saw the resident raise the cup to her mouth, but did not watch her finish taking the medications or ensure the cup was empty before leaving. MA-D stated she thought the resident took all of the medications, but later acknowledged the medications should not have been left unattended. The DON stated medications were expected not to be left at the bedside and that staff should make sure all medications were consumed before leaving the room. The facility policy stated medications and biologicals are to be stored securely and accessible only to authorized personnel.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to initiate cardiopulmonary resuscitation (CPR) for a resident who was documented as full code status. The resident, an elderly female with diagnoses including unspecified dementia and congestive heart failure, was under hospice care but had a clear physician's order and care plan indicating full code status. On the night of the incident, the resident was observed by a certified nursing assistant (CNA) to be breathing abnormally and was reported to the LVN, who assessed the resident and noted a faint pulse and imminent passing. The LVN left the bedside to verify the resident's code status, initially checking the hospice binder and then the electronic health record, which confirmed full code status. Despite confirming the resident's full code status, the LVN did not initiate CPR when the resident became unresponsive. Instead, the LVN instructed the CNA to perform post-mortem care. The LVN later stated that she was distracted by a personal emergency and mistakenly assumed that all hospice patients had do-not-resuscitate (DNR) orders, despite the documentation to the contrary. No vital signs were documented for the resident on the date of the incident, and emergency medical services were not contacted. The medical director confirmed that the expectation was for staff to follow physician orders, and that failure to do so could have impacted the resident's outcome. Interviews with facility staff, including the director of nursing (DON), CNA, and the administrator, confirmed that the LVN did not follow the established protocols for a resident with full code status. The facility's policies required that CPR be initiated for residents without a heartbeat or not breathing, in accordance with their advance directives and physician orders. The LVN's actions were inconsistent with these policies and the resident's documented wishes, resulting in the resident not receiving CPR prior to her death.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the review of resident records and care plans, where it was noted that the care plan did not comprehensively cover all identified needs, nor did it include clear, measurable goals or interventions.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Document Weekly Skin Assessments for At-Risk Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents by not documenting weekly skin assessments as required. For one resident with severe cognitive impairment and significant physical assistance needs, there was no evidence of weekly skin inspections for multiple weeks, despite the resident being at risk for pressure ulcers and having no current skin issues. Another resident, who was cognitively intact but required substantial assistance and had stage 4 pressure ulcers, also lacked documentation of weekly skin assessments for several weeks, even though wound care orders and a care plan were in place for her pressure ulcers. A third resident, also with severe cognitive impairment and high risk for pressure ulcers, did not have weekly skin assessments documented for an extended period, despite her care plan indicating the need for extensive assistance and monitoring for potential pressure ulcer development. Observations and interviews confirmed that staff performed skin checks during care activities, and CNAs completed shower sheets, but these assessments were not consistently documented in the electronic medical record as required by facility policy. Interviews with nursing staff, the ADON, DON, and the administrator revealed that charge nurses were responsible for completing and documenting weekly skin assessments in the electronic system. However, changes in the electronic medical record system and competing duties contributed to missed documentation. The DON and ADON acknowledged the failure to document, attributing it to system updates and workflow challenges, but maintained that skin assessments were being performed even if not recorded.
Failure to Provide Timely Supervision During Smoke Breaks Resulting in Resident Altercation
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and that residents received adequate supervision and assistive devices to prevent accidents, specifically during scheduled smoke breaks. Two residents with significant cognitive and behavioral diagnoses, including dementia, depression, and agitation, were left unsupervised while waiting for staff to facilitate their smoke break. During this unsupervised period, an altercation occurred between the two residents, resulting in physical contact, though no injuries were reported. The care plans for both residents indicated the need for supervision and monitoring during off-unit activities and smoke breaks. Multiple interviews and observations revealed that staff were frequently late to supervise scheduled smoke breaks, particularly on weekends. Residents reported waiting unsupervised for extended periods, sometimes up to an hour past the scheduled time. Staff interviews confirmed that the smoking schedule was not consistently followed, and there was confusion and reluctance among staff regarding who was responsible for supervising smoke breaks. The issue was known to facility leadership, and the posted schedule was not reliably adhered to, especially during weekends and evenings. Documentation and interviews indicated that the lack of timely staff supervision during smoke breaks led to resident agitation and altercations. Staff acknowledged the recurring problem of delayed smoke breaks and the resulting resident frustration, which included yelling, hitting, and property damage. The facility's failure to provide adequate supervision and maintain a safe environment during these times directly contributed to the incident between the two residents.
Infection Control Lapse During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper hand hygiene and glove use by a Certified Nursing Assistant (CNA) during incontinence care for a resident. The resident, a 67-year-old female with Alzheimer's disease and incontinence, required substantial assistance with activities of daily living. During the care, the CNA did not change gloves or perform hand hygiene after handling a soiled brief and before placing a clean brief on the resident, despite her gloves being visibly soiled with urine. The CNA acknowledged the lapse in infection control practices, stating she should have changed gloves before handling the clean brief. She had received infection control training the previous month but failed to apply it during the care. The Director of Nursing (DON) was aware of some concerns regarding infection control practices and noted that the Assistant Director of Nursing (ADON) was responsible for infection control training and monitoring. The facility's infection control policy emphasized the importance of hand hygiene and glove changes, which were not adhered to in this instance.
Failure to Obtain Consent for Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident #50 and Resident #114, or their representatives, were informed and provided consent for the administration of antipsychotic medications. Resident #50, a male with moderate cognitive impairment, was receiving Ziprasidone for schizoaffective disorder, but there was no evidence of a signed consent form (HHSC Form 3713) by the resident or their representative. Similarly, Resident #114, a male with severe cognitive impairment, was receiving Seroquel for dementia and insomnia, yet there was no signed consent form on record. The Director of Nursing (DON) acknowledged that the antipsychotic consent forms should have been signed before the medications were administered. The DON stated that the oversight was due to staff turnover and lack of monitoring, which she was responsible for during weekly team meetings. The absence of signed consent forms meant that residents and their representatives might not have been aware of the medications being administered and their potential side effects. The facility's policy on psychotropic drugs requires written consent from the resident or their representative before administering new psychotropic medications. The policy explicitly states that verbal consent is not acceptable, and nursing facility staff cannot sign on behalf of the resident. The report highlights that the prescriber or their designee must complete the relevant section of the consent form, and the resident or their legally authorized representative must sign it, as per the Texas Health and Human Services Commission guidelines.
Failure to Refer Resident for PASRR Screening
Penalty
Summary
The facility failed to refer a resident for a PASRR screening and evaluation, which is required for individuals with newly evident mental disorders or related conditions. This deficiency involved a resident who was admitted with a negative PL1, indicating no previous history of mental illness. However, upon admission, the resident had a significant past history of depression, anxiety, and PTSD, which was not initially recognized or acted upon by the facility. The resident's medical records revealed a primary diagnosis of Bipolar disorder, along with other diagnoses such as Generalized Anxiety Disorder and PTSD, which were identified after admission. Despite these diagnoses, the facility did not refer the resident for a PASRR re-evaluation, which is necessary to ensure that residents receive adequate services or care related to mental illnesses. The MDS Coordinator later acknowledged the oversight and submitted the necessary documentation for a new PASRR evaluation, but this was done only after an internal audit highlighted the issue. Interviews with facility staff, including the MDS Coordinator and the Area Director of Operations, revealed a lack of familiarity with the required procedures and forms, such as Form 1012, which should have been completed and processed for the resident. The facility's policy on PASRR specialized services did not address the necessary steps to take when a resident with a negative PL1 is later diagnosed with a psychiatric condition, contributing to the oversight.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals, as observed in two medication carts and one medication room. Specifically, expired medications were not disposed of from the Hall A-D nurse medication cart, and pharmacy labels were missing on insulin flex pens from the Hall B nurse medication cart. Additionally, the facility did not maintain medication count sheets for controlled substances in the Hall G-H medication room, which could lead to undetected shortages of medication. Resident #2, a male with type 2 diabetes, had an insulin flex pen without a pharmacy label, only marked with the resident's last name and open date. Similarly, Resident #111, a female with type 2 diabetes, had an insulin flex pen without prescribed dose information. These labeling deficiencies were noted during observations, and interviews with staff revealed a lack of awareness and adherence to labeling protocols. The facility's Director of Nursing (DON) and other staff members acknowledged the absence of count sheets for controlled substances and the presence of expired medications. The DON confirmed that count sheets were required for controlled medications and that expired medications should be removed from carts. Interviews with pharmacy representatives highlighted the expectation for proper labeling and disposal of medications, emphasizing the potential for medication misappropriation and reduced therapeutic effects due to these deficiencies.
Deficiency in Food Temperature and Quality
Penalty
Summary
The facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for four residents and one kitchen. Residents expressed concerns about the food being cold, lacking flavor, and having poor texture. Specifically, Resident #120 reported that breakfast was usually cold and the food overall was not very good, although lunch on the day of the visit was better but still cold. Resident #376 mentioned that the food was inconsistent, often cold, and lacked condiments, which was a recurring topic at monthly council meetings. Resident #8 also noted that cold food was a frequent issue discussed at resident council meetings, attributing it to delays in tray distribution. During an observation, a test tray was prepared and served, revealing that the food temperatures were below acceptable levels, with spinach at 117.5°F, hamburger steak with cheese at 100.2°F, and mashed potatoes at 117.1°F. The Dietary Manager and surveyors sampled the food and confirmed it was cold and did not meet expectations. The facility's policy on Daily Food Temperature Control, dated 2012, stated that food should be served within acceptable temperature ranges, which was not adhered to in this instance.
Food Safety and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen. Staff members did not wear effective hair restraints, which resulted in hair hanging out of their nets. This was observed with multiple dietary aides, whose hair was not fully contained, potentially leading to contamination of food and utensils. The facility's policy required clean hair to be totally covered with an effective hair restraint, which was not followed. Additionally, staff did not practice appropriate hand hygiene during meal preparation. One staff member, identified as [NAME] G, was observed cutting a cake without gloves, touching the cake with her bare hands, and handling various items without washing her hands in between tasks. Another staff member, Dietary Aide H, was seen wearing gloves while performing multiple tasks, including handling trash, without changing gloves or washing hands, which could lead to cross-contamination. Dietary Aide I was observed handling silverware by the eating end and touching her face without washing her hands afterward. Interviews with the staff revealed a lack of awareness and adherence to the facility's infection control policies. [NAME] G admitted to wearing acrylic nails, which was not addressed in the facility's policy, and acknowledged not following proper hand hygiene. Dietary Aide H and I also recognized their failures in maintaining hygiene standards. The Dietary Manager and Supervisor, both relatively new to the facility, acknowledged these lapses and the potential for cross-contamination, indicating a need for better enforcement of existing policies.
Failure to Update Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to address the resident's medical, nursing, and psychosocial needs. Specifically, the care plan did not address the resident's edema in the lower extremities and his refusal to comply with care instructions. This oversight was identified during a review of the resident's records, which showed that despite having physician orders for knee-high compression stockings and leg elevation to manage edema, these were not incorporated into the care plan. The resident, a male with severe cognitive impairment, had diagnoses including Down syndrome, peripheral vascular disease, and aortic valve insufficiency. Despite documented orders and observations of significant edema, the care plan was not updated to reflect these needs. The Interim DON acknowledged the omission, attributing it to her being new to the role and still learning the system. The facility's policy mandates that care plans should include all identified needs, but this was not adhered to in this case.
Inaccurate Skin Assessment Documentation
Penalty
Summary
The facility failed to ensure that the medical record for a resident was complete and accurately documented, specifically regarding skin assessments. The resident, a male with severe cognitive impairment and multiple medical conditions including Down syndrome, peripheral vascular disease, and aortic valve insufficiency, was found to have several unstageable pressure areas and a deep tissue pressure injury that were not present upon admission. Despite these conditions, a weekly skin assessment completed by an LVN inaccurately documented the resident's skin as intact. Interviews revealed that the RN was unaware of why the LVN did not document the assessment accurately, suggesting a possible lack of knowledge on how to fill out the form properly. The facility's administrator emphasized the importance of accurate documentation and reporting of new skin concerns to prevent worsening conditions. The facility's policy mandates complete and accurate documentation for each resident, which was not adhered to in this case.
Failure to Notify Family of Resident's Emergency Transfer
Penalty
Summary
The facility failed to immediately inform a resident's power of attorney (POA) and resident representative when there was a significant change in the resident's condition. This deficiency involved a resident who had a change in condition that required transportation via ambulance to a hospital. The resident, who had severe cognitive impairments and was rarely understood, was not accompanied by family members during this critical time due to the facility's failure to notify them promptly. The incident occurred when the resident experienced a change in condition that necessitated emergency medical services. Despite the urgency, the responsible nurse, RN C, did not contact the resident's POA or family members immediately after the resident was transported to the hospital. The POA was only informed of the situation by a hospital employee several hours later, which resulted in the family losing valuable time that could have been spent with the resident during a distressing period. Interviews with facility staff, including the Director of Nursing (DON) and the Administrator, revealed that the nurse failed to adhere to the expected protocol of notifying the family, physician, and relevant administrative staff. The DON and other staff members expressed that the nurse's actions did not meet the facility's expectations, emphasizing the importance of family presence during emergencies for the resident's comfort and advocacy. The failure to notify the family promptly was identified as a deficiency, as it deprived the resident of familial support during a critical time.
Failure to Notify Resident's Representative and Inaccurate Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, leading to a deficiency in documentation practices. The incident involved a resident with severe cognitive impairment and multiple medical conditions, including dementia, hypothyroidism, depression, and hypertension. The resident experienced a change in condition and was transported to the hospital via ambulance. However, the responsible party was not notified of this change, contrary to what was documented in the resident's medical records. The documentation by RN C inaccurately stated that the resident's family and other relevant parties were notified of the resident's transfer to the hospital. This false documentation was later admitted by RN C, who acknowledged that she had not contacted the resident's power of attorney (POA) or family. The discrepancy in the records was discovered after the resident's POA reported not being informed about the resident's condition change and hospital transfer. Interviews with facility staff, including the Director of Nursing (DON) and the Administrator, revealed that they were unaware of the failure to notify the resident's POA until the following day. The facility's policy required complete and accurate documentation, which was not adhered to in this case. The inaccurate documentation could lead to miscommunication and anxiety for the resident and their family.
Deficiency in Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that the call light systems in the rooms of two residents were in good working order, which is necessary for providing adequate supervision and assistance to prevent accidents. Resident #3, a female with severe cognitive impairment due to Alzheimer's, and Resident #7, a female with cognitive impairment and dementia, were both affected by this deficiency. The care plans for both residents emphasized the importance of having the call light within reach to ensure a safe environment and to mitigate the risk of falls due to their cognitive impairments. Observations revealed that the call light system in Resident #7's room was not within reach, with the string being only 8 inches long, making it inaccessible for residents sitting or lying in bed. Resident #7 was unaware of the call light system and had never used it. Interviews with staff, including a CNA and the Administrator, indicated a lack of awareness regarding the non-functional call light system. The CNA mentioned that call lights were not frequently used in the secure unit, and the Administrator was unaware of the issue until it was brought to her attention, at which point she repaired the system.
Improper Hoyer Lift Transfer by CNA
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and provide adequate supervision for a resident requiring assistance with transfers. A certified nursing assistant (CNA) improperly transferred a resident using a Hoyer Lift without the required two-person assistance, as specified in the resident's care plan and physician's orders. The resident, who had a history of muscle weakness, lack of coordination, and repeated falls, reported hitting his head during the transfer, resulting in a bump but no visible injuries upon assessment. Interviews revealed that the CNA was aware of the two-person requirement but proceeded alone due to the absence of other aides and the resident's insistence on being transferred quickly. The facility's policies and the manufacturer's guidelines for the Hoyer Lift also indicated the necessity of two-person assistance for safe operation. Despite the CNA's training on mechanical lifts, the incident occurred, highlighting a lapse in adherence to established safety protocols.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 109 citations issued within 25 miles in the last 12 months — including the 7 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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) |
|---|---|---|---|---|
| Trinity Nursing & Rehab Of Granbury | 1.2 mi | ★★★★★ | 3 | 0 |
| Granbury Rehab & Nursing | 1.6 mi | ★★★★★ | 20 | 0 |
| Harbor Lakes Nursing And Rehabilitation Center | 1.9 mi | ★★★★★ | 8 | 0 |
| Glen Rose Nursing And Rehab Center | 14.2 mi | ★★★★★ | 10 | 0 |
| Cherokee Rose Nursing And Rehabilitation | 14.6 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.