Health inspection·February 19, 2026

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 Page 1 of 3 455915 455915 02/19/2026 Granbury Care Center 301 S Park St Granbury, TX 76048

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 455915 Page 2 of 3 455915 02/19/2026 Granbury Care Center 301 S Park St Granbury, TX 76048

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. 455915 Page 3 of 3