Health inspection·September 12, 2025

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few (Electronic Health Record) and it said full code. I thought it was a mistake. I did not honor her code status. In an interview on [DATE] at 1:50 am, CNA B said on [DATE] at about 12:00 am, I went to check on and change [Resident #1] and she was having trouble breathing, I went and told [LVN A], the nurse went down with me to check her. [LVN A] said she didn't look good, and she went back to the nurses' station to look at computer. I stayed with [Resident #1], she got worse, she stopped breathing and had a blank staring off look. I went and got [LVN A] again. She came and took her vitals, told me she stopped breathing and passed, and told me to perform post-mortem care. [LVN A] did not initiate CPR. In an interview on [DATE] at 2:15 pm, the Medical Director said Resident #1 had an order for full code. He said it was his expectation for staff to follow the physician's orders. He said in this instance, failing to follow physician's orders had the potential that the resident's life could have been saved. In an interview on [DATE] at 3:19 pm, Resident #1's Family Member, he said LVN A called him sometime after midnight on [DATE] telling him that Resident #1 stopped breathing and did not have a DNR in place. He thought LVN A had told him CPR had been attempted but was too distraught to know for sure. In interview and record review on [DATE] at 10:30 am, the Administrator said he was no longer the Administrator of the facility since [DATE]. He said he was the Administrator of the facility during the time of the incident. He said he reported the incident and the LVN should have initiated CPR on Resident #1 who was a full code status. Record review of the facility policy Cardiopulmonary Resuscitation, not dated, revealed the following [in part]: Cardiopulmonary resuscitation (CPR) is a method of providing systemic circulation by manual chest compression and oxygen by mouth-to-mouth breathing or providing air to the lungs via ambu-bag. The procedure is preformed to prevent death following cardiac or pulmonary arrest . Record review of the facility policy Self Determination End of Life Measures, not dated, revealed the following [in part]: Policy: 2. Upon admission, the facility will provide the individual with a copy of her/her rights under Texas law concerning the right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives.3.The facility will respect the wishes of the resident as outlined in the advanced directive . A record review of the facility policy Resident Rights, not dated, revealed the following [in part]: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her equality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Planning and Implementing Care - the Resident has the right to be informed of, participate in, his or her treatment including:b. The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and d uratin of care and any other factors related to the effectiveness of the plan of care. Self-Determination: The resident has the right to and the facility must promote and facilitate resident self-determination through support of the resident choice. 2. The Resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. 12. The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). The facility prior to investigator entrance on [DATE] completed the following corrections/interventions. The facility was evaluated to be in past noncompliance based on the corrections implemented prior to entrance. 1. Self-reporting protocol initiated on [DATE]. 2. [DATE] at 2:15 am, the Administrator was notified by the hospice nurse of Resident #1 passing that was full code and LVN A did not initiate CPR or contact emergency services. 3. Ad Hoc QAPI on [DATE] for Resident who was on hospice services but chose to have full (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455915 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455915 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Granbury Care Center 301 S Park St Granbury, TX 76048 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few code status, had passed away and the nurse did not initiate a code. 4. LVN A was immediately suspended on [DATE].5. The Administrator notified the DON, ADON, MD, Responsible Party, Social Services, Ombudsman, and Regional Team notified on [DATE]. Investigation started by the facility on [DATE]. Obtained witness statements. 7. The DON audited all resident code status on [DATE] - reviewed orders, care plans, DNRs. No errors were found. 8. Staff in-services were initiated on abuse/neglect, CPR, Advanced Directives, Resident Rights, Notification of Change, How to identify code status, and Following Physician Orders. Sign-in sheets observed. Quizzes were completed. The DON said all staff have been in-serviced except for a few PRN staff that hasn't worked in a while and before they return to work, they will have to complete the in-services before they will be allowed to work. Initiated [DATE]. 9. Safe surveys were conducted with residents on the LVNs hallway on [DATE], no further concerns were identified. 10. LVN A was terminated, and her nursing license was referred to the Texas Board of Nursing on [DATE]. 11. Daily monitoring by DON was ongoing. Verification of Correction 1: In an interview on [DATE] at 11:00 am, the DON said she received a call from the Administrator on [DATE] at 4:30 am in the morning about the incident. The LVN was immediately suspended and terminated after an investigation and her nursing licenses was referred to the Texas Board of Nursing all on [DATE]. The DON audited all residents' code status', making sure they were completed, care plans were correct, and physician's orders were reviewed. There were no errors found. A memo was put out for staff to not assume if a resident was on hospice care that did not mean they were not full code and how to find the code status in PCC (Electronic Health Record). In-servicing staff with a competency quiz was initiated. All staff had been in-serviced except for a few PRN staff who hadn't worked in a while. When they returned to work, they would be required to complete the in-services before being able to work. Hospice services had been contacted regarding the incident and reviewed with them the 2 residents that were currently under hospice care who were also full codes in the facility. Daily monitoring was ongoing at this time by the DON, including during the stand-up meetings to identify any evidence of any potential neglect, and during facility rounds were there any signs of staff performing or not performing their duties in a neglect manner. At the facility, per policy, CNAs were not CPR certified, only the nurses were. The facility policy states only 1 person must be in the facility per shift that is CPR certified. LVNs could not pronounce death, only RNs could do that. In this instance the LVN contacted hospice who came and pronounced death. Record review of the facility reporting protocol template indicated all areas of the self-reporting protocol had been completed, dated and signed by staff. Verification of Correction 2:In an interview on [DATE] at 2:20 pm, the Hospice DON said the incident was reviewed in their morning stand up meeting on [DATE]. She said the hospice nurse arrived at the facility an hour after the incident at approximately 1:00 am and noted that Resident #1 was full code status, and that CPR had not been initiated. The hospice nurse did contact Resident #1's family member and he did not want anything else done at that time. She contacted the Administrator of the facility on [DATE] at 2:15 am and reported the incident to him. Verification of Correction 3:Record review of the Ad Hoc QAPI meeting revealed the meeting was conducted on [DATE] with the following members attended: Medical Director, Administrator, DON, ADON #1, ADON #2 , MDS Nurse #1, MDS Nurse #2, Area Director of Operations, and the Regional Compliance Nurse. Verification of Correction 4:Record review of the Employee Disciplinary Report dated [DATE] revealed the LVN A was suspended for investigation of failing to do CPR. Verification of Correction 5:Record review of the Provider Investigation Report, dated [DATE] revealed the Administrator, DON, ADON, Medical Director, the Resident Representative, Social Services, Ombudsman and the facility Regional Team were notified that LVN A failed to initiate CPR or notify EMS for Resident #1 that was full code status. Verification of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455915 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455915 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Granbury Care Center 301 S Park St Granbury, TX 76048 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Correction 6:Record review of documentation including the Provider Investigation Report dated [DATE] and the Self-Reporting protocol dated [DATE] revealed the facility investigation of the incident was started on [DATE] at 2:15 am by the Administrator. Verification of Correction 7:Record review of the 13 sampled Resident Code Status' were reviewed that included the advanced directives, physician's orders, and care plans. No errors were found. Verification of Correction 8:Record review in-service training records sign-in sheets and quizzes revealed completion by all active staff. Interviews with the following 12 sampled staff revealed all stated they had received in-service training including abuse/neglect, advance directives, CPR, resident rights, code status' and following physician's orders that included completing a competency quiz. They were not allowed to work until the in-services had been completed. [DATE] at 1:50 pm, CNA BXXX[DATE] at 11:29 am, CMA CXXX[DATE] at 11:55 am, Social WorkerXXX[DATE] at 11:12 am, CMA DXXX[DATE] at 11:24 am, CNA E.9/11.25 at 11:27 am, CNA FXXX[DATE] at 11:34 am, LVN GXXX[DATE] at 11:38 am, LVN HXXX[DATE] at 11:44 am, Rehabilitation ManagerXXX[DATE] at 11:48 am, CNA IXXX[DATE] at 11:52 am, CMA JXXX[DATE] at 11:57 am, CNA K. Verification of Correction 9:Record review revealed the residents on LVN A's hallway were interviewed with no additional concerns identified regarding the LVN. The resident's all said staff were respectful and appropriate, denied staff were rude or spoken abusively to, felt safe, knew how to report abuse, who the abuse coordinator was and did not express any concerns with their treatment and care. In interviews with the following sampled residents revealed none of them expressed concerns with staff. [DATE] at 11:27 am, Resident #2XXX[DATE] at 11:31 am, Resident #4XXX[DATE] at 11:35 am, Resident #3XXX[DATE] at 11:41 am, Resident # 5XXX[DATE] at 11:45 am, Resident #6. Verification of Correction 10:Record review of LVN A's employee file revealed a termination date of [DATE]. Record review of referral to Texas Board of Nursing was completed on [DATE] at 2:54 pm. Record review revealed LVN A's CPR certification was current, expiring on 03/2027. Verification of Correction 11:Record review of documentation monitoring revealed it was on-going daily since [DATE]. No further concerns have been identified. Event ID: Facility ID: 455915 If continuation sheet Page 4 of 4