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 Page 1 of 4 675084 675084 11/27/2023 Trinity Nursing & Rehab of Granbury 600 Reunion Court Granbury, TX 76048

F 0761 locked compartment of cart. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/27/2023 at 11:32 a.m., DON stated that it was appropriate to give resident multiple attempts to take medications. He stated that the expectation would be for the nurse not to lock medication cup on the cart but to keep in nurse's hand. The DON stated that the resident not taking medication when it was offered lead to the failure. He would not provide a negative effect the failure could have on a resident. DON stated that he and pharmacy representatives were responsible for monitoring that the charge nurses were storing medication appropriately. He stated that the last time pharmacy representatives were in the building was on November 7, 2023. Residents Affected - Few During an interview on 11/27/2023 at 11:35 a.m., Corporate RN B stated that it was okay to re-attempt to give medication to a resident up to three times or until medication was past ordered time. He voiced that it was appropriate for medication to remain in cup of pudding and that it did not interfere with pharmacological factors for up to an hour. He expected that the nurse would have kept the medication cup with unlabeled medication in hand until medication would be given or destroyed. He stated that he expected a nurse to lock medication on the cart in the pudding cup if there was an emergency pulling nurse to another resident. He did not state the negative effect the failure could have on residents. RN B stated that policy did state controlled medications should be stored under two locks. Record review of facility policy labeled Storage of Medication last revised on November 2020 revealed: Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers .The nursing staff is responsible for maintaining medication storage and preparation areas .Schedule II-V controlled medication are stored in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medications. 675084 Page 2 of 4 675084 11/27/2023 Trinity Nursing & Rehab of Granbury 600 Reunion Court Granbury, TX 76048

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to provide food that accommodates resident's preferences for one (Resident #1) of four residents reviewed for food preferences. The facility failed to ensure Resident #1 did not receive her dislike food (peas) during the lunch meal on 11/22/2023 and failed to label her meal tickets with her likes and dislikes. This failure could affect all residents with food preferences and could result in a decrease in resident choices and weight loss from diminished interest in meals. The findings included: Record review of Resident #1's face sheet revealed a [AGE] year-old female admitted on [DATE] with most recent return date 07/06/2023. Her diagnosis includes respiratory failure (lung disease), chronic obstructive pulmonary disease (lung disease), muscle weakness, atrial fibrillation (irregular pulse), heart failure (heart disease), and type 2 diabetes. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 08 meaning moderately impaired. Record review of Resident #1's care plan dated 11/20/2023 revealed no evidence of dislike preference of peas. Record review of Resident #1's lunch meal card dated 11/22/2023 revealed no likes or dislikes listed and no handwritten notes present. Record review of Resident #1's food preference record dated 07/19/2023 revealed dislikes by category .vegetables .peas. Record review of the current weekly menu, dated 11/22/2023, revealed Wednesday's scheduled lunch meal was fried pork chip with gravy, black-eyed peas, mixed greens, cornbread, pudding with whipped topping. During an observation on 11/22/2023 at 11:53 a.m. revealed Resident #1 was served black-eyed peas with her lunch. During an interview on 11/22/2023 at 10:09 a.m., CNA C stated that it was the CNAs responsibility to take meal tickets for the following day around to resident's rooms and ask if resident wanted changes to menu. She stated that CNAs would circle on the meal ticket what residents wanted or write on ticket if there was a special request. She stated that if resident did not like what was being served during mealtimes, CNA would go to kitchen and get an alternate food item. During an interview on 11/22/2023 at 11:53 a.m., Resident #1 stated that she was not asked 11/21/2023 what her preferences were for 11/22/2023 meals. She stated that she had complained about being served her dislikes in the past and she continued to be served her dislikes. She stated that she did not think staff cared about her requests at times and that made her think that facility did not care 675084 Page 3 of 4 675084 11/27/2023 Trinity Nursing & Rehab of Granbury 600 Reunion Court Granbury, TX 76048

F 0806 about her. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 11/22/2023 beginning at 11:53 a.m., CNA C stated that she did not work on 11/21/2023. She stated that normally the tickets would have handwritten notes on them with resident's requests. CNA C was serving meal tray to Resident #1 who reported that she would not eat anything that was served. CNA C asked Resident #1 if she would like something different and requested alternate food provided. Residents Affected - Few During an interview on 11/22/2023 at 2:49 p.m., DM stated that she monitored resident's likes and dislike preferences. She stated that she was new to the DM role and that she did see where previous dietary manager had performed food preference assessment on Resident #1 on 07/19/2023. She stated that after food preference assessment was performed, DM would then enter information into system so that resident's likes and dislikes would be printed on meal ticket. She believed the failure of meal ticket not having likes and dislikes was due to them not being inputted into system correctly. She stated that CNA know where to get meal ticket for the next day and that they should go room to room notifying residents of what will be served and ask if residents want alternate. She stated that Resident #1 was good about writing what her preference was on meal tickets. She stated that a resident should not be served peas if they have a documented dislike for peas. She stated the failure could cause the resident not to eat the food. During an interview on 11/27/2023 at 11:24 a.m., ADMN stated that it as her expectation that residents were asked about likes and dislikes and be inputted into system. She stated that residents should be asked the day before about their meal preference and staff were to write on meal tickets if alternative food requested. She stated that the charge nurses and DON were expected to monitor that preferences were followed. She stated that she believed accountability led to the failure of resident not being offered chooses the day prior. She stated that another failure was staff not following steps inputting likes and dislikes into software to be printed on tickets and that had been corrected since 11/22/2023. She did not state any negative effects this could have on residents. The ADMN stated that residents may not remember their requests from the prior day and alternates were offered during meals. Record review of facility in-service labeled Resident Meal Tickets dated 11/20/2023 revealed: Resident's meal tickets are given approx. 10 am every day for the next day's meal. It is the CNAs responsibility to ask what each resident would like. Always ask and do not write down what you think they would want. NPO are exempt. Tickets are to be turned in at 6pm before you leave for the day. Record review of facility policy labeled Nutritional Assessment last revised on October 2017 revealed: As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factor for impaired nutrition, shall be conducted for each resident .The nutritional assessment will be conducted by the multidisciplinary team and shall identify at least the following components .Food preferences and dislikes (including flavors, textures, and forms) .Individualized care plan shall address, to the extent possible the resident's personal preferences. 675084 Page 4 of 4