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Inspection visit

Health inspection

Granbury Care CenterCMS #4559158 citations on this visit
8 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free of any significant medication error reviewed 5 of 5 (LVN E, LVN I, LVN J, LVN K and ADON A) staff reviewed for Insulin use. The facility failed to ensure LVN E held Resident #102's Lantus 100 Units/ML two (2) times when his blood glucose was under 120 for a two (2)-month review period. The facility failed to ensure LVN I held Resident #102's Lantus 100 Units/ML thirteen (13) times when his blood glucose was under 120 for a two (2)-month review period. The facility failed to ensure LVN J held Resident #102's Lantus 100 Units/ML three (3) times when his blood glucose was under 120 for a two (2)-month review period. The facility failed to ensure LVN K held Resident #102's Lantus 100 Units/ML six (6) times when his blood glucose was under 120 for a two (2)-month review period. The facility failed to ensure ADON A held Resident #102's Lantus 100 Units/ML six (1) times when his blood glucose was under 120 for a two (2)-month review period. These failures could place residents at risk of not receiving care and services to meet their needs. Findings include: Record review of Resident #102's face sheet, dated 02/19/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #102's medical diagnoses included dementia, psychotic disturbance, mood disturbance, and anxiety, mild cognitive impairment, morbid obesity, schizophrenia, essential hypertension, type 2 diabetes, and acute kidney failure. Record review of Resident #102's Annual MDS, dated [DATE], revealed in Section C - Cognitive Patterns-C0500 a BIMS Summary Score 09, which indicated the resident was moderately impaired. Section N-Medications, documented Resident #102 received Insulin. Record review of Resident #102's Comprehensive Care Plan, initiated 09/10/2023 and reviewed/revised 04/22/2025, revealed the following focused areas: Focus: Diabetes Mellitus: insulin dependent Goal: The resident will be free from any s/sx of hyperglycemia (High blood sugars). The resident will have no complications related to diabetes. The resident will be free from any s/sx of hypoglycemia (low blood sugar).Intervention Task: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Record review of Resident #102's physician order, with a start date of 04/05/2024 and a revision date of 08/04/2025, revealed: Lantus SoloStar Subcutaneous Solution Pen-injector 100UNIT/ML (Insulin Glargine), Inject 10 unit subcutaneously one time daily for hyperglycemia Hold if <120. Record review of Resident #102's electronic MAR for the months of January 2026, and February 2026 revealed insulins being administered when blood glucose was <120 revealed: 01/01/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 115 recorded by LVN-K.01/02/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 103 recorded by LVN-I.01/04/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 118 recorded by LVN-I. 01/16/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 117 recorded by LVN-I. 01/17/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 107 recorded by LVN-I. 01/19/2026 Lantus soloStar Subcutaneous Residents Affected - Some (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 455915 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 02/19/2026 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Solution 100 UNIT/ML 10 units one time a day with blood glucose of 107 recorded by LVN-K.01/20/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 118 recorded by LVN-K. 01/23/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 102 recorded by LVN-K. 01/24/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 104 recorded by LVN-J. 01/25/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 91 recorded by LVN-J. 01/26/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 84 recorded by LVN-A. 01/30/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 92 recorded by LVN-I. 01/31/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 99 recorded by LVN-I.02/01/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 103 recorded by LVN-I. 02/02/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 118 recorded by LVN-K. 02/03/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 110 recorded by LVN-K. 02/04/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 114 recorded by LVN-I.02/05/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 units one time a day with blood glucose of 114 recorded by LVN-I.02/07/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 one time a day with blood glucose of 109 recorded by LVN-E. 02/08/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 one time a day with blood glucose of 102 recorded by ADON-A 02/09/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 one time a day with blood glucose of 93 recorded by LVN-I.02/11/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 one time a day with blood glucose of 107 recorded by LVN-E.02/13/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 one time a day with blood glucose of 101 recorded by LVN-I.02/14/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 one time a day with blood glucose of 101 recorded by LVN-I.02/15/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 one time a day with blood glucose of 111 recorded by LVN-I.02/16/2026 Lantus SoloStar Subcutaneous Solution 100 UNIT/ML 10 one time a day with blood glucose of 99 recorded by LVN-J. During an interview on 02/18/2026 at 3:10 PM, LVN-E stated if there was a check mark on the MAR with letters, it would have meant the medication had been administered to the resident. She stated if there was blood sugar below the parameter of 120, she would hold the insulin and check it again at a later time. LVN-E stated if she had a resident with a sliding scale, she would give/hold the insulin depending on the doctor's order and what the sliding scale was in place. She stated there would not have been any reason for her to give insulin if the blood sugar were outside the parameters. She stated if insulin was given if below the parameters, the side effects of the residents could bottom out (low blood sugar), then they would have to give something to bring the sugars back up. LVN-E stated it was the nurse's responsibility to document in the MAR whether the medication was given or not. She stated she felt the order for Resident #102 used to have an order with no parameters and did not know when it had changed to having parameters. During an interview on 02/18/2026 at 3:38 PM, the DON stated the medication Lantus for Resident #102's order had a parameter to hold if less than (<) 120. She stated if there was a check mark, it meant the medication was given. The DON stated she felt there was an order of no parameter a couple of months ago. She stated if doctors change orders they were discussed in the twenty-four (24) hour report. She stated if you had a blood sugar below the parameters the insulin should be held and if there was an order change or update, the LVN's and RNs should be aware of the change. She stated the nurses are briefed on changes during IDT meetings. The DON stated if you give insulin outside of those parameters, the side (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455915 If continuation sheet Page 2 of 3 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 02/19/2026 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete effects could be hypoglycemia (low blood sugar) and could have led to hospitalization and/or death. She stated the failure occurred with the nurses not paying attention to updated order changes and the DON for not monitoring the nurses close enough. During an interview on 02/18/2026 at 4:06 PM, MD-L, during a returned phone call, he stated if Resident #102's sugar was under the parameter, the nurses should not be giving his Lantus SoloStar Subcutaneous medication. He stated all nurses administering medications should have followed orders and it was his expectations to do so. Record review of the facility policy Physician Orders, dated 2015 revealed: Purpose:To monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident. Written Orders by the Physician or Nurse Practitioner:1. Nurse will review the order and if needed contact the prescriber for any clarifications2. The nurse will enter the order into PCC for the resident and select prescriber written3. If the order requires documentation, it will be directed to the proper electronic administration record once the order is completed. 4. The receiving nurse will contact any other department or external facilities as required, i.e. dietary department, pharmacy, lab provider, x-ray provider, etc. Event ID: Facility ID: 455915 If continuation sheet Page 3 of 3

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Citations

8 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0700GeneralS&S Dpotential for harm

    F700 - Bed Rails

    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

  • 0761GeneralS&S Dpotential for harm

    F761 - Labeling of Drugs and Biologicals

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  • 0812GeneralS&S Epotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0842GeneralS&S Epotential for harm

    F842 - Resident-identifiable information

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0909GeneralS&S Epotential for harm

    F909 - Conduct Regular inspection of all bed frames, mattresses, and bed

    Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

  • 0552GeneralS&S Dpotential for harm

    F552 - Planning and Implementing Care

    Ensure that residents are fully informed and understand their health status, care and treatments.

  • 0605GeneralS&S Dpotential for harm

    F605 - Respect and Dignity

    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

  • 0760GeneralS&S Epotential for harm

    F760 - Residents are free of any significant medication errors

    Ensure that residents are free from significant medication errors.

FAQ · About this visit

Common questions about this visit

What happened during the February 19, 2026 survey of Granbury Care Center?

This was a inspection survey of Granbury Care Center on February 19, 2026. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Granbury Care Center on February 19, 2026?

Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for ..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.