Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Trinity Nursing & Rehab Of Granbury during CMS and state inspections, most recent first.
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.
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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What surveyors actually found near you
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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.
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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 | 1 |
| Harbor Lakes Nursing And Rehabilitation Center | 1.5 mi | ★★★★★ | 8 | 0 |
| Granbury Rehab & Nursing | 2.8 mi | ★★★★★ | 20 | 0 |
| Glen Rose Nursing And Rehab Center | 14.7 mi | ★★★★★ | 10 | 0 |
| Cherokee Rose Nursing And Rehabilitation | 15.2 mi | ★★★★★ | 11 | 0 |
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