Health inspection·November 27, 2023

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (South Hall) of 4 medication carts reviewed for medication labeling and storage. The facility failed to ensure that all medications stored in South Hall medication cart were stored in their original container/packaging. The facility failed to ensure that all medications stored in South Hall medication cart were properly labeled. The facility failed to ensure that controlled medication in South Hall medication cart were stored under a double locking system. These failures placed all residents at risk of harm or decline in health due to lack of potency of medications/biologicals or misappropriation of medications. The findings included: During observation on 11/27/2023 at 10:15 a.m., the South Hall medication cart in the top drawer, there was one clear medication cup with morning medications outside of their original containers and placed inside with some vanilla pudding. The clear medication cup was covered with white paper cup that had Resident #2's first name written on it and a wooden spoon stuck out of the side of cup. During an interview on 11/27/2023 at 10:15 a.m., LVN A stated she had prepared medication in cup earlier this morning and had attempted to administer to Resident #2, but resident refused. LVN A stated the loose medications included: Sucralfate 1 gram tablet (medication that helps prevent and heal stomach ulcers), Vimpat 100 mg tablet (controlled schedule V medication that reduces seizure activity), Coreg 3.125mg tablet (medication that helps reduce pulse or blood pressure), Seroquel 50mg tablet (medication that helps reduce symptoms of psychotic disorders), amlodipine 10mg tablet (medication that helps reduce elevated blood pressure), memantine 5mg tablet (medication that helps with dementia), potassium chloride 20 mEq ER tablet (medication that helps gain potassium). She stated that she left medication in cup on top drawer to re-attempt administering medication after she passed medication on another hall. She stated it was not appropriate to leave medications in cup on top shelf and that she should have disposed. She stated that Vimpat medication was to be stored under a second (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 4 Event ID: 675084 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 11/27/2023 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)