Health inspection·July 3, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to a meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #6, Resident #7) of 8 residents reviewed for comprehensive person-centered care plans.1. The facility failed to develop care plans based on assessed needs with measurable objectives in the areas of Hemiplegia/Hemiparesis, Hypertension, GERD, Dementia, and Anxiety for Resident #1.2. The facility failed to develop care plans based on assessed needs with measurable objectives in the areas of Parkinson's Disease, Hypertension, Diabetes Mellitus, diuretic therapy, edema, GERD, and renal failure for Resident #2.3. The facility failed to develop care plans based on assessed needs with measurable objectives in the areas of Parkinson's Disease, Diabetes Mellitus, and edema for Resident #3.4. The facility failed to develop care plans based on assessed needs with measured objectives in the areas of Anticoagulant Therapy, hypertension, bowel incontinence, GERD, and dementia for Resident #4.5. The facility failed to develop care plans based on assessed needs with measurable objectives in the areas of Diabetes, Atrial Fibrillation, Crohn's Disease, osteoporosis, asthma, and GERD for Resident #6. 6. The facility failed to develop care plans based on assessed needs with measurable objectives in the areas of Hemiplegia, Seizure Disorder, History of Vascular accident with residual right sided Hemiplegia, and COPD for Resident #7.These failures could affect the residents by placing them at risk for not receiving care and services to meet their needs.The findings included:Resident #1Record review of Resident #1's Facesheet, dated 07/03/2025, revealed Resident #1 was a [AGE] year-old female, with an admission date into the facility of 09/08/2023. Diagnoses included Unspecified Dementia (diagnosis given when a person's cognitive impairment was not clearly categorized into a specific type of dementia), Hemiplegia (paralysis on one side of the body) and Hemiparesis (weakness on one side of the body) following cerebral infarction (condition where a part of the brain tissue dies due to lack of blood flow) affecting left non-dominant side, Hypertension (condition where the force of blood against the artery wall was consistently too high), Generalized Anxiety Disorder (mental health condition characterized by excessive, uncontrollable, and often irrational worry about everyday events or activities), and GERD (digestive disorder where stomach acid flows back into the esophagus, causing symptoms like heartburn or regurgitation).Record review of Resident #1's Quarterly MDS, dated [DATE], revealed Resident #1's BIMS score was 05, which indicated severe cognitive impairment. Section I - Active Diagnoses revealed Resident #1 had medically complex conditions, with diagnoses of Dementia, Generalized Anxiety Disorder, GERD, Hypertension, and Hemiplegia/Hemiparesis following cerebral infarction.Record review of Resident #1's Care Page 1 of 7 455915 455915 07/03/2025 Granbury Care Center 301 S Park St Granbury, TX 76048

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Plan with recent review of 03/03/2025 revealed objectives lacking ability to be evaluated, quantified, and verified were: The resident will remain free of complications or discomfort related to Hemiplegia/Hemiparesis; the resident will remain free of complications related to hypertension through the review date; the resident will remain free of discomfort, complications, or s/sx related to dx of GERD; the resident will be free from s/sx of complications of cardiac problems; the resident will remain oriented to (person, place, situation, time) though the review date (related to Dementia); and the resident will have no indications of psychosocial well-being problems by/through review date.Resident #2Record review of Resident #2's Facesheet, dated 07/03/2025, revealed Resident #2 was a [AGE] year-old male, with an admission date into the facility of 09/03/2024. Diagnoses included Type II Diabetes Mellitus with foot ulcer (a chronic metabolic disorder characterized by high blood sugar levels due to the body's inability to properly use insulin and/or insufficient insulin production), Essential Hypertension (a condition characterized by persistently high blood pressure without a known secondary cause), Parkinsonism (a term used to describe a group of neurological disorders characterized by motor symptoms such as tremors, rigidity, and slow movement), Acute Kidney Failure (a sudden and rapid decrease in kidney function), localized Edema (condition characterized by swelling caused by fluid retention in body tissues), GERD (digestive disorder where stomach acid flows back into the esophagus, causing symptoms like heartburn or regurgitation), and enlarged and hypertrophic nails (abnormal thickening of the nail plate).Record review of Resident #2's Significant Change in Condition MDS, dated [DATE], revealed Resident #2's BIMS score was 15, which indicated intact cognition. Section I - Active Diagnoses revealed Resident #1 had medically complex conditions, with diagnoses of Anemia, GERD, Dementia, Diabetes Mellitus, Parkinsonism, and Essential Hypertension. Record review of Resident #2's Care Plan with recent review of 06/30/2025 revealed objectives lacking ability to be evaluated, quantified, and verified were: The resident will remain free of further s/sx, discomfort, or complications related to Parkinson's disease; [Resident #2] will remain free of complication related to hypertension; the resident will be free from any s/sx of hyperglycemia (a condition where there is too much glucose in the blood), have no complications related to diabetes, and the resident will be free from any s/sx of hypoglycemia (a condition where the level of glucose in your blood drops too low, often below 70 mg/dl); [Resident #2] will be free of any discomfort or adverse side effect of diuretic therapy; the resident's fluid balance will improve and not worsen; the resident will remain free from discomfort, complications, and s/sx related to dx of GERD; [Resident #2] will have no s/sx of complications relate to fluid overload through the review date (related to acute kidney disease); [Resident #2] will have no s/sx of complications related to fluid overload; the resident's ulcer (diabetic ulcer) will improve by review date; and the resident will maintain current level of cognitive function. Further review of comprehensive care plan reviewed there was no evidence of a focus, objective, or interventions related to enlarged and hypertrophic nails.Resident #3Record review of Resident #3's Facesheet, dated 07/01/2025, revealed Resident #3 was a [AGE] year-old female, with an admission date into the facility of 11/16/2024. Diagnoses included Neuroleptic induced Parkinsonism (a movement disorder that resembles Parkinson's disease but was caused by certain medications, particularly antipsychotics), Type II Diabetes Mellitus (a chronic metabolic disorder characterized by high blood sugar levels due to the body's inability to properly use insulin and/or insufficient insulin production), Edema (condition characterized by swelling caused by fluid retention in body tissues), Unspecified Dementia (diagnosis given when a person's cognitive impairment was not clearly categorized into a specific type of dementia), and GERD (digestive disorder where stomach acid flows back into the esophagus, causing symptoms like heartburn or regurgitation).Record review of 455915 Page 2 of 7 455915 07/03/2025 Granbury Care Center 301 S Park St Granbury, TX 76048

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #3's Quarterly MDS, dated [DATE], revealed Resident #3's BIMS score was not calculated. C0100, Should Brief Interview for Mental Status (C0200 - C0500) be Conducted was coded 0 for No resident was rarely/never understood; therefore, BIMS score was not determined. Section I - Active Diagnoses revealed Resident #3 had Other Neurological Condition, as I0020 was coded 07. Active diagnoses included Neuroleptic induced Parkinsonism, Unspecified Dementia, Edema, Primary Osteoarthritis, GERD, and Diabetes Mellitus. Record review of Resident #3's Care Plan with recent review of 12/13/2024 revealed objectives lacking ability to be evaluated, quantified, and verified were: The resident will remain free of further s/sx, discomfort, or complications related to Parkinson's disease; the resident will be free from any s/sx of hyperglycemia through review date; [Resident #3] will have no complications related to diabetes; the resident's fluid balance will improve or not worsen through the next review date; [Resident #3] will remain free from discomfort, complications, or s/sx related to dx of GERD; and [Resident #3] will maintain current level of cognitive function through review date. Further review of comprehensive care plan reviewed there was no evidence of a focus, objective, or interventions related to Primary Osteoarthritis. Resident #4Record review of Resident #4's Facesheet, dated 07/03/2025, revealed Resident #4 was an [AGE] year-old female, with an admission date into the facility of 01/30/2025. Diagnoses included Other Alzheimer's Disease (most common form, where a person experienced the effects of more than one type of dementia), Cellulitis (bacterial infection of the skin and underlying tissue caused by bacteria) of unspecified part of limb, Hypothyroidism (when the thyroid gland does not make and release enough hormone into the bloodstream), GERD (digestive disorder where stomach acid flows back into the esophagus, causing symptoms like heartburn or regurgitation), Paroxysmal Atrial Fibrillation (type of irregular heartbeat where the heart's upper chambers beat chaotically and rapidly, causing the heart to beat irregularly and often too fast), and Essential (Primary) Hypertension (a condition characterized by persistently high blood pressure without a known secondary cause).Record review of Resident #4's Quarterly MDS, dated [DATE], revealed Resident #4's BIMS score was 06, which indicated severe cognitive impairment. Section I - Active Diagnoses revealed Resident #4 had medically complex conditions, with diagnoses of Hypertension, Alzheimer's Disease, Anxiety Disorder, Hypothyroidism, Paroxysmal Atrial Fibrillation, and GERD. Record review of Resident #4's Care Plan with recent review of 05/01/2025 revealed objectives lacking ability to be evaluated, quantified, and verified were: The resident would be free from discomfort or adverse reactions related to anticoagulant use through the review date; the resident would remain free of complications related to hypertension through the review date; the resident would not have any complications r/t bowel incontinence; the resident will remain free from discomfort, complications, or s/sx related to dx of GERD through review date; the resident would be free from s/sx of complications of cardiac problems through review date; and the resident would maintain current level of cognitive function through the review date. Further review of comprehensive care plan reviewed there was no evidence of a focus, objective, or interventions related to cellulitis. Resident #6Record review of Resident #6's Facesheet, dated 07/03/2025, revealed Resident #6 was an [AGE] year-old female, with an admission date into the facility of 12/23/2020. Diagnoses included Legal blindness (a severe level of vision impairment, defined as having a visual acuity of 20/200 or less in the better-seeing eye with corrective lenses, or as restricted visual field of 20 degrees or less), Type II Diabetes Mellitus (a chronic metabolic disorder characterized by high blood sugar levels due to the body's inability to properly use insulin and/or insufficient insulin production), Atrial Fibrillation (type of irregular heartbeat where the heart's upper chambers beat chaotically and rapidly, causing the heart to beat irregularly and often too fast), Crohn's Disease (chronic inflammatory bowel disease that can 455915 Page 3 of 7 455915 07/03/2025 Granbury Care Center 301 S Park St Granbury, TX 76048

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some affect any of part of the digestive tract), Hyperlipidemia (condition where there are elevated levels of lipids, including cholesterol and triglycerides, in the blood), Essential (Primary) Hypertension (a condition characterized by persistently high blood pressure without a known secondary cause), osteoporosis (a disease that weakens bones, making them more likely to break), GERD (digestive disorder where stomach acid flows back into the esophagus, causing symptoms like heartburn or regurgitation), Unspecified Asthma (a diagnosis of asthma where the specific type or severity was not documented), and Obstructive Sleep Apnea (a sleep disorder where the upper airway repeatedly collapse or becomes blocked during sleep, causing pauses in breathing or shallowing breathing). Record review of Resident #6's Annual MDS, dated [DATE], revealed Resident #6's BIMS score was 13, which indicated intact cognition. Section I - Active Diagnoses revealed Resident #1 had medically complex conditions, with diagnoses of Atrial Fibrillation, Hypertension, Crohn's Disease, Diabetes Mellitus, Hyperlipidemia, Thyroid Disorder, Legal blindness, Anxiety Disorder, and Gout.Record review of Resident #6's Care Plan with recent review of 08/14/2024 revealed objectives lacking ability to be evaluated, quantified, and verified were: [Resident #6] will have no complications related to diabetes through the review date; Resident will remain free from s/sx of pacemaker malfunction or failure through the review period; Resident will be free from discomfort or adverse reactions related to anticoagulant use through the review period; Resident will remain free from discomfort, complications, or s/sx related to gastrointestinal alterations through the review period; (related to osteoporosis) Resident will remain free from or at a level of discomfort acceptable to the resident through the review period; Resident will be free from s/sx of complications of poor circulation through the review period; Resident will remain free of complications related to hypertension through the review period; Resident will remain free of s/sx related to hypothyroidism through the review period; Resident will remain free of discomfort, complications, or s/sx related to dx of GERD through the review period; and Resident will maintain optimal quality of life within limitations imposed by visual function through the review period. Resident #7Record review of Resident #7's Facesheet, dated 07/03/2025, revealed Resident #7 was a [AGE] year-old male, with an admission date into the facility of 06/25/2025 . Diagnoses included Chronic Obstructive Pulmonary Disease (progressive lung disease that makes it hard to breathe), Epilepsy (neurological disorder characterized by seizures due to abnormal electrical activity in the brain), Hyperlipidemia (condition where there are elevated levels of lipids, including cholesterol and triglycerides, in the blood), Hemiplegia affecting right dominant side (paralysis on one side of the body), Primary generalized osteoarthritis (a degenerative joint disease characterized by the breakdown of cartilage, leading to pain, stiffness, and reduced range of motion in the affected joints), and Cerebral Infarction (a condition where a part of the brain was damaged due to a lack of blood supply. Record review of Resident #7's Annual MDS, dated [DATE], revealed Resident #7's BIMS score was 15, which indicated intact cognitive response. Section I - Active Diagnoses revealed Resident #7 had Debility (physical weakness, especially as a result of illness), Cardiorespiratory Conditions. Diagnoses included Hyperlipidemia, Seizure Disorder, Bipolar Disorder, Asthma, Chronic Obstructive Pulmonary Disease, and Cerebral Infarction. Record review of Resident #7's Care Plan with recent review of 08/14/2024 revealed objectives lacking ability to be evaluated, quantified, and verified were: The resident will be free from complications or discomfort related to Hemiplegia through the review date; the resident will be free from injury related to seizure activity through the review date; the resident will show improvement to maximum potential with mobility and cognition by review date (related to Cerebral Vascular Accident); resident will maintain current level of mobility (related to arthritis); and resident will have a stable mood (related to seizures). During an interview on 455915 Page 4 of 7 455915 07/03/2025 Granbury Care Center 301 S Park St Granbury, TX 76048

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 07/03/2025 at 10:32 a.m., the MDS Coordinator said the residents' goals and outcomes were developed through the IDT process. The MDS Coordinator said she was aware the outcomes were not measurable as written, and she had not been trained on how to write measurable outcomes.During an interview on 07/03/2025 at 12:01 p.m., the DON said the outcome for Resident #3, the resident would have fewer episodes thorough review date (in the area of behavior problems related to dementia) was vague and unmeasurable. The DON said the importance of having measurable outcomes was to show progress of the services that were provided to the resident. The DON said it was part of the monitoring process to determine if the residents met their goals with the appropriate service.During an interview on 07/03/2025 at 12:43 p.m., the Administrator said he expected all outcomes in the residents' care plans to be measurable. The Administrator said outcomes needed to be measurable to track data and ensure services were being provided accurately and consistently. Record review of the facility's policy, Comprehensive Care Planning, not dated, revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. 455915 Page 5 of 7 455915 07/03/2025 Granbury Care Center 301 S Park St Granbury, TX 76048

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to make sure that the comprehensive care plan was prepared by an interdisciplinary team that included a nurse aide with responsibility for the resident for 8 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, and Resident #8) of 8 residents reviewed for care plans. The facility failed to ensure the nurse aides with responsibility for the residents were invited and attended the resident care plan conferences. These failures could place the residents at risk for not receiving the care and services to meet their needs.The findings included: Resident #1: Record review of Resident #1's Facesheet, dated 07/03/2025, revealed Resident #1 was a [AGE] year-old female, with an admission date into the facility of 09/08/2023. Diagnoses included Unspecified Dementia (diagnosis given when a person's cognitive impairment was not clearly categorized into a specific type of dementia). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed Resident #1's BIMS score was 05, which indicated severe cognitive impairment. Resident #2 Record review of Resident #2's Facesheet, dated 07/03/2025, revealed Resident #2 was a [AGE] year-old male, with an admission date into the facility of 09/03/2024. Diagnoses included Type II Diabetes Mellitus with foot ulcer (a chronic metabolic disorder characterized by high blood sugar levels due to the body's inability to properly use insulin and/or insufficient insulin production). Record review of Resident #2's Significant Change in Condition MDS, dated [DATE], revealed Resident #2's BIMS score was 15, which indicated intact cognition. Resident #3 Record review of Resident #3's Facesheet, dated 07/01/2025, revealed Resident #3 was a [AGE] year-old female, with an admission date into the facility of 11/16/2024. Diagnoses included Neuroleptic induced Parkinsonism (a movement disorder that resembles Parkinson's disease but was caused by certain medications, particularly antipsychotics). Record review of Resident #3's Quarterly MDS, dated [DATE], revealed Resident #3's BIMS score was not calculated. C0100, Should Brief Interview for Mental Status (C0200 - C0500) be Conducted was coded 0 for No - resident was rarely/never understood; therefore, BIMS score was not determined. Resident #4 Record review of Resident #4's Facesheet, dated 07/03/2025, revealed Resident #4 was an [AGE] year-old female, with an admission date into the facility of 01/30/2025. Diagnoses included Other Alzheimer's Disease (most common form, where a person experienced the effects of more than one type of dementia). Record review of Resident #4's Quarterly MDS, dated [DATE], revealed Resident #4's BIMS score was 06, which indicated severe cognitive impairment. Resident #5 Record review of Resident #5's Facesheet, dated 07/03/2025, revealed Resident #5 was a [AGE] year-old female, with an admission date into the facility of 07/16/2018. Diagnoses included Cerebral Palsy, Unspecified (a group of neurological disorders that appear in infancy or early childhood and permanently affect a person's movement and muscle coordination. Record review of Resident #5's MDS, dated [DATE], revealed Resident #5's BIMS score was not calculated. C0100, Should Brief Interview for Mental Status (C0200 - C0500) be Conducted was coded 0 for No - resident was rarely/never understood; therefore, BIMS score was not determined. Resident #6 Record review of Resident #6's Facesheet, dated 07/03/2025, revealed Resident #6 was an [AGE] year-old female, with an admission date into the facility of 12/23/2020. Diagnoses included Legal blindness (a severe level of vision impairment, defined as having a visual acuity of 20/200 or less in the better-seeing eye with corrective lenses, or as restricted visual field of 20 degrees or less). Record review of Resident #6's Annual MDS, dated [DATE], revealed Resident #6's BIMS score was 13, which indicated intact cognition. Resident #7 Record review of Resident #7's Facesheet, dated 07/03/2025, revealed Resident #7 was a [AGE] year-old male, with an admission date into the facility of 06/25/2025 . 455915 Page 6 of 7 455915 07/03/2025 Granbury Care Center 301 S Park St Granbury, TX 76048

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Diagnoses included Chronic Obstructive Pulmonary Disease (progressive lung disease that makes it hard to breathe), Epilepsy (neurological disorder characterized by seizures due to abnormal electrical activity in the brain). Record review of Resident #7's Annual MDS, dated [DATE], revealed Resident #7's BIMS score was 15, which indicated intact cognition. Resident #8 Record review of Resident #8's Facesheet, dated 07/03/2025, revealed Resident #8 was a [AGE] year-old female, with an admission date into the facility of 03/11/2024. Diagnoses included Hemiplegia (paralysis on one side of the body) and Hemiparesis (weakness on one side of the body) following cerebral infarction (condition where a part of the brain tissue dies due to lack of blood flow) affecting Right dominant side. Record review of Resident #8's Quarterly MDS, dated [DATE], revealed Resident #8's BIMS score was 13, which indicated intact cognition. During an interview on 07/01/2025 at 7:57 a.m., CNA D said he did not attend or participate in the IDT meetings of any of the residents in the facility. CNA D said he had never been invited to attend. CNA D said he had important information to share at the meetings because he knew the residents very well since he interacted with the residents during his entire shift. CNA D said he knew what the residents liked and disliked and how to communicate with residents who were non-verbal. During an interview on 07/02/2025 at 1:39 p.m., CNA E said she did not attend care plan meetings and had not been invited to any of the residents' IDT care plan meetings who he provided services to in the facility. During an interview on 07/02/2025 at 3:25 p.m., CNA F said she did not attend care plan meetings. CNA F said the facility was often short staffed and the direct care could not leave the floor to attend a meeting. CNA F said she had never been invited. During an interview on 07/03/2025 at 10:32 a.m., the MDS Coordinator said the facility sent out notifications to the members of the IDT team. The MDS Coordinator said she did not invite the CNAs because she knew the CNAs had difficulty attending the care plan meetings due to their direct care responsibilities and the facility did not want to pull them off the halls. The MDS Coordinator said she was aware CNAs were required members of the IDT. During an interview on 07/03/2025 at 12:01 p.m., the DON said she was aware the CNAs were part of the IDT were required to attend the care plan meetings. The DON said it was important for the CNAs to be involved in the care planning process because the aides spent the most time with the residents and provided the actual services. Record review of the facility's policy, Comprehensive Care Planning, not dated, revealed, A comprehensive care plan will be - Prepared and/or contributed to by an interdisciplinary team, that includes but is not limited to -- *A nurse aide with the responsibility for the resident. 455915 Page 7 of 7