Health inspection·March 29, 2023

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure as needed (PRN) orders for psychotropics drugs were limited to 14-days, for six residents (Resident #4, Resident #11, Resident #14, Resident #22, Resident #28, and Resident #30) of twelve residents reviewed for unnecessary psychotropic medications. The facility had an order for the psychoactive medication alprazolam (Xanax) PRN (as needed) for Resident #4, Resident #14, Resident #22, Resident #28, and Resident #30, and an order for lorazepam (Ativan) PRN for Resident #11 for more than 14 days, without an evaluation by the physician(s) for the appropriateness of the medications. This failure could place all residents on psychoactive medications at risk for receiving unnecessary medications. The findings were: Record review of Resident #4's electronic face sheet revealed Resident #4 was an [AGE] year-old female admitted to the facility on [DATE]. The resident had a BIMS score of 9 out of 15 indicating moderate cognitive impairment. Resident #4's diagnoses included dementia, anxiety, chest pains, depression, pain in left shoulder, mood disturbances, high blood pressure, nerve pain, and weakness. Physician orders dated 01/30/2023 included alprazolam (Xanax) 0.5 mg by mouth twice a day as needed for anxiety. The end date for the order was 04/30/2023. Record review of Resident #4's Medication Administration Record for February and March 2023 revealed Resident #4 received one as needed dose of alprazolam (Xanax) 0.5 mg on 03/20/23 at 01:41 AM for behaviors. Record review of Resident #4's progress notes dated 03/20/2023 at 05:11 PM revealed Resident with confused behaviors and refusal to take her medicine still noted. However, after a lot of redirecting, resident agreed to take her medicines. Will continue to monitor behaviors. The entry was signed Facility Agency LVN 1. Record review of Resident #11's electronic face sheet revealed Resident #11 was an [AGE] year-old female admitted to the facility on [DATE]. The resident had a BIMS score of 0 out of 15 indicating severe cognitive impairment. Resident #11's diagnoses included dementia, anxiety, respiratory disease, depression, weight loss, mood disturbances, high blood pressure, nerve pain, and weakness. The physician orders dated 01/30/2023 included lorazepam (Ativan) 2 mg/mL; amt: 0.5 mL as needed by mouth every 2 hours for anxiety. The end date for the order was 07/31/2023. Physician orders dated 01/30/23 included lorazepam (Ativan) 2 mg/mL; amt: 0.25 mL by mouth as needed every 2 hours for anxiety. The end date for the order was 07/31/2023. Record review of Resident #11's Medical Record for February and March 2023 revealed no documentation of the resident receiving lorazepam (Ativan). Record review of Resident #14's electronic face sheet revealed Resident #14 was a [AGE] year-old female admitted to the facility on [DATE]. The resident had a BIMS score of 0 out of 15 indicating (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675084 If continuation sheet Page 2 of 6 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 675084 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Nursing & Rehab of Granbury 600 Reunion Court 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some severe cognitive impairment. Resident #14's diagnoses included dementia, anxiety, respiratory disease, depression, weight loss, mood disturbances, high blood pressure, nerve pain, and weakness. Physician orders dated 01/30/2023 included alprazolam (Xanax) 1 mg as needed by mouth every 4 hours for anxiety. The end date for the order was 04/30/2023. Record review of Resident #14's Medical Record for February and March 2023 revealed no documentation of the resident receiving alprazolam (Xanax). Record review of Resident #22's electronic face sheet revealed Resident #22 was a [AGE] year-old male admitted to the facility on [DATE]. The resident had a BIMS score of 9 out of 15 indicating moderate cognitive impairment. Resident #22's diagnoses included dementia, anxiety, depression, right side paralysis, blood clots, pain, and obesity. Physician orders dated 03/05/2023 included alprazolam (Xanax) 0.25 mg as needed by mouth every 8 hours for anxiety. The end date for the order was 06/24/2023. Record review of Resident #22's Medical Record for February and March 2023 revealed no documentation of the resident receiving alprazolam (Xanax). Record review of Resident #28's electronic face sheet revealed Resident #28 was a [AGE] year-old male admitted to the facility on [DATE]. The resident had a BIMS score of 13 out of 15 indicating intact cognition. Resident #28's diagnoses included anxiety, depression, respiratory disease, high blood pressure, pain, and malnutrition. Physician orders dated 01/30/2023 included alprazolam (Xanax) 0.25 mg as needed by mouth every 8 hours for anxiety. The end date for the order was 05/02/2023. Record review of Resident #28's Medical Record for February and March 2023 revealed no documentation of the resident receiving alprazolam (Xanax). Record review of Resident #30's electronic face sheet revealed Resident #30 was a [AGE] year-old female admitted to the facility on [DATE]. The resident had a BIMS score of 0 out of 15 indicating severe cognitive impairment. Resident #30's diagnoses included brain damage, anxiety, stiffness of arms and legs, depression, inability to speak, feeding tube, and breathing tube. Physician orders dated 01/30/2023 included alprazolam (Xanax) 1 mg as needed by gastric tube every 8 hours for anxiety. The end date for the order was 04/30/2023. Record review of Resident #30's Medical Record for February and March 2023 revealed no documentation of the resident receiving alprazolam (Xanax). During an interview on 03/29/23 at 03:20 PM, the DON stated a psychotropic medication remaining on a resident's orders beyond the 14-day limitation would need a reason to continue to have the order on the MAR. She stated there was no sense in a medication still sitting there if the resident does not need it. The DON stated a resident could be overmedicated if an unnecessary PRN dose was administered. The DON explained the failure may have occurred due to new nurses and agency nurses not checking for stop dates on PRN medications. She stated she and the ADON went thru all the GDRs and audited stop dates recently. She stated she understood the Physician cannot not document con't Rx as a rationale to decline the pharmacy consultant's recommendations for a gradual dose reduction or to extend a psychotropic medication stop date. The DON stated she was aware the physician must evaluate the resident and document a specific rationale. She stated she felt like the nursing staff she has now knows to watch for a stop date and follow-up with the prescriber. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675084 If continuation sheet Page 3 of 6 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 675084 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Nursing & Rehab of Granbury 600 Reunion Court 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 03/29/23 at 03:27 PM, the Administrator stated she could not answer the question on why the failure to follow policy on PRN psychotropic medications occurred. She stated she assumed the DON and ADON were responsible for monitoring renewal dates on PRN psychotropic medications. The Administrator described potential consequences to residents not reevaluated for a need of a psychotropic medication every 14 days was that a resident may receive a medication they do not need. She continued by stating, If the resident does not need the medication, it needs to be removed from the orders. She concluded by stating if the resident does need the medication and takes regularly, the prescribers order should be changed to a scheduled dose. During an interview on 03/29/23 at 04:01 PM, the CCL stated the cause of failure occurred when the PRN psychotropic medications report was generated, the parameters were based on medication category therefore no medications were flagged. She explained when generating a report on medications, the parameters should be based on drug classification. She stated not all meds were entered into the correct category due to multiple staff entering physician orders. This caused the system to produce an incorrect list. During an interview on 03/29/23 at 04:05 PM, the DON stated all nurses were trained to enter prescriber orders. She explained the training was conducted by the DON and ADON when a nurse was hired. The DON stated she opened the electronic records system and went through the whole system with the nurse. Facility policy titled Medication Monitoring Medication Management dated 01/22, Section 8.4, page 8 of 12 under PRN Orders for Psychotropic and Antipsychotic Medications stated, The attending physician or prescribing practitioner must document the diagnosed specific condition and indication for the PRN medication in the medical record. Type of PRN order: PRN orders for psychotropic medications, excluding antipsychotics. Limitation: 14 days. Exception: Order may be extended beyond 14 days if the attending physician or prescribing practitioner believes it is appropriate to extend the order. Required Action: Attending physician or prescribing practitioner should document the rationale for the extended time period in the medical record and indicate a specific duration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675084 If continuation sheet Page 4 of 6 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 675084 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Nursing & Rehab of Granbury 600 Reunion Court 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen's reviewed for food safety, in that: Residents Affected - Some Items in freezer #1 were not labeled identify items and dated with opened/use by dates. Items in the large refrigerator were not labeled and dated with opened/use by dates past 7 days. These failures placed residents that eat food from the kitchen at risk for foodborne illnesses. Findings included: During an observation and interview on 03/27/2023 beginning at 10:45 AM of the 1 kitchen revealed: Large refrigerator 1 white container of green diced substance, that DM identified as diced peppers, not labeled to identify item, and dated 2/24. 1 white container of green diced substance, that DM identified as diced peppers, not labeled to identify item, and dated 2/16. Freezer #1 22 bags of what the DM identified as waffles not labeled to identify item and not dated with opened/use by dates. 1 bag of what the DM identified as carrots not labeled to identify item and not dated with opened/use by dates. 1 large plastic bag filled with what the DM identified as pancakes not labeled to identify item and not dated with opened/use by dates. 1 clear green bag tied shut with what the DM identified breakfast sausage patties not labeled to identify item and not dated with opened/use by date. 6 slabs of what the DM identified as meat not labeled to identify item and not dated with opened/use by dates. 5 rolls of what the DM identified as hamburger meat not labeled to identify item and not dated with opened/use by dates. I 5-gallon brown tub of what the DM identified as ice cream not labeled to identify item and not dated with opened/use by dates. During an interview on 03/27/23 at 11:00 AM, the DM stated that everything should have been labeled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675084 If continuation sheet Page 5 of 6 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 675084 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Nursing & Rehab of Granbury 600 Reunion Court 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and dated. He stated anything out of the original package should have been labeled and dated. He stated that all these items' things were labeled improperly. He stated this could pose a risk to the residents by them receiving expired food which could make them sick or receiving foods that they may be allergic too since the food is not labeled. The DM stated it was his responsibility to ensure items were dated and labeled properly. He stated he had only worked in the facility for 1 month and had been working on getting everything labeled and dated. Record Review of Facility Policy labeled Food Storage dated October 2019 revealed: The dining services director or designee ensures that all packages and canned food items shall be kept clean, dry, and properly sealed . The dining services director or designee ensure that the storage will be neat, arranged for easy identification, and date marked as appropriate . The dining services director ensures that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. Record Review of United States Food and Drug Administration (USFDA) accessed https://www.fda.gov/media/127796/download at on 03/31/2022 revealed: Section 3-501.17 specifies ready-to-eat, time/temperature control for safety (TCS) food prepared in a food establishment and held longer than a 24 hour period shall be marked to indicate the date or day by which the food is to be consumed on the premises, sold, or discarded when held at a temperature of 5°C (41°F) or less for a maximum of 7 days. These time/temperature parameters are intended to help control for growth of Listeria monocytogenes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675084 If continuation sheet Page 6 of 6