Health inspection·June 4, 2025

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the residents' medical symptoms for 2 (Resident #8 and Resident #39) of 18 residents reviewed for unnecessary medications. 1. The facility failed to ensure Resident #8's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or document a rationale for the continued provision of the medication. 2. The facility failed to ensure Resident #39's PRN Hydroxyzine (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or document a rationale for the continued provision of the medication. This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication and dependence on unnecessary medications. Findings included: Resident #8 Review of Resident #8's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: anxiety, depression, and schizoaffective disorder. Review of Resident #8's quarterly MDS assessment dated [DATE], revealed a BIMS score of 11 which indicated moderate cognitive impairment. Review of Section N: Medications revealed Resident #8 was receiving anti-anxiety medications. Review of Resident #8's Comprehensive Care Plan last revised 04/03/2025, revealed: Problem: Resident has the potential for complications related to antianxiety medication use .Approach: Administer medication per MD orders, monitor for any side effects. Review of Resident #8's electronic Physicians Orders revealed: lorazepam tablet; 0.5 mg; amt: 1 tab; oral Special Instructions: May administer 1-2 tabs Every 2 Hours, start date 03/19/2025 with no stop date. Review of Resident #8's May 2025 MAR revealed no doses of Lorazepam were administered. Page 1 of 19 675084 675084 06/04/2025 Trinity Nursing & Rehab of Granbury 600 Reunion Court Granbury, TX 76048

F 0605 Level of Harm - Minimal harm or potential for actual harm Review of Resident #8's June 2025 MAR up until 06/03/2025, revealed no doses of Lorazepam were administered. Review of Resident #8's physician progress notes revealed no evidence of documented rationale to order PRN Lorazepam for more than 14 days. Residents Affected - Few Review of Drugs.com for Lorazepam accessed on 06/04/2025 at https://www.drugs.com/lorazepam.html revealed: Lorazepam belongs to a class of medications called benzodiazepines. It is thought that benzodiazepines work by enhancing the activity of certain neurotransmitters in the brain. Lorazepam is used in adults and children at least [AGE] years old to treat anxiety disorders. Resident #39 Review of Resident #39's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: heart failure, anxiety, and diabetes. Review of Resident #39's Quarterly MDS dated [DATE], revealed a BIMS score of 13 which indicated no cognitive impairment. Review of Section N: Medications revealed Resident #39 was not receiving anti-anxiety medication. Review of Resident #39's Comprehensive Care Plan last revised 05/30/2025 revealed no evidence of resident medication for anxiety. Review of Resident #39's electronic Physicians Orders revealed: hydroxyzine tablet; 10 mg; amt: 1 tab; oral Special Instructions: 1 tab at bedtime prn or 2 as tolerated/needed At Bedtime for anxiety, start date 03/11/2025 discontinued 05/29/2025 and hydroxyzine tablet; 10 mg; amt: 1 tab; oral Special Instructions: 1 tab at bedtime prn or 2 as tolerated/needed At Bedtime start date 05/29/2025 with no stop date. Review of Resident #39's May 2025 MAR revealed 12 doses of hydroxyzine was administered. Review of Resident #39's June 2025 MAR up until 06/03/2025, revealed 3 doses of hydroxyzine was administered. Review of Resident #39's physician progress notes revealed no evidence of documented rationale to order PRN hydroxyzine for more than 14 days. Review of Drugs.com for Hydroxyzine accessed on 06/04/2025 at https://www.drugs.com/ hydroxyzine.html revealed: hydroxyzine also reduces activity in the central nervous system, it can be used as a sedative to treat anxiety and tension. During an interview on 06/04/25 at 03:31 PM, the DON stated prn psychotropic medications cannot be given for longer than 14 days without a new order or physician documentation for the need to continue past 14 days. He stated this could lead to over-sedation or possible seclusion. He stated he just overlooked and missed these orders. He stated he was responsible for reviewing orders. Review of the facility's policy titled; Psychoactive Medication Use dated July 2024 revealed in part: Policy Statement: Residents are not given psychotropic medications unless the drug is necessary to treat a specific condition, as diagnoses and documented in the clinical record, and the medication 675084 Page 2 of 19 675084 06/04/2025 Trinity Nursing & Rehab of Granbury 600 Reunion Court Granbury, TX 76048

F 0605 Level of Harm - Minimal harm or potential for actual harm is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. Guidelines: .7. PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e 14 days). Residents Affected - Few 675084 Page 3 of 19 675084 06/04/2025 Trinity Nursing & Rehab of Granbury 600 Reunion Court Granbury, TX 76048

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the comprehensive assessment accurately reflected the resident's status for 4 (Resident #32, Resident #25, Resident #21, and Resident #39) of 18 Residents reviewed for accuracy of assessments. Residents Affected - Some The facility failed to ensure MDS dated [DATE] reflected the use of oxygen for Resident #32. The facility failed to ensure MDS dated [DATE] reflected hospice services for Resident #25. The facility failed to ensure MDS dated [DATE] reflected hospice services for Resident #21. The facility failed to ensure MDS dated [DATE], reflected the use of anti-anxiety medications for Resident #39. This failure could residents at risk of inaccurate assessments and not receiving appropriate care according to their status. Findings include: Resident #32 Review of Resident #32's electronic face sheet reflected a [AGE] year-old male originally admitted on [DATE] re-admitted on [DATE] with diagnoses that included: fusion of spine (surgery to fuse spine), quadriplegia (loss of motor and sensory function in all limbs and the trunk), weakness, pneumonia (infection in the lungs), and chronic obstructive pulmonary disease (disorder that effects air flow in and out of the lungs). Review of Resident #32's quarterly MDS assessment dated [DATE] reflected: BIMS score of 13 meaning his cognition was intact. Further review of MDS reflected resident was not on oxygen therapy. Review of Resident #32's comprehensive care plan initiated 12/11/2024 reflected: Problem: resident has an as needed oxygen therapy order related to emphysema/COPD and personal history of smoking .Approach: Administer oxygen at as needed 1-4 l/min via nasal cannula. Observe oxygen precautions. Record review of Resident #32's electronic physician order dated 07/30/2024 reflected: oxygen to be administered via nasal cannula as needed at 1-4 l/min for quadriplegia (loss of motor and sensory function in all limbs and the trunk). Further review of order reflected physician order was discontinued on 05/29/2025. Record review of Resident #32's electronic physician order dated 05/29/2025 reflected: oxygen to be administered via nasal cannula as needed at 1-4 l/min for quadriplegia (loss of motor and sensory function in all limbs and the trunk). During an observation on 06/02/2025 at 11:32 a.m., Resident #32 was sitting up in a wheelchair in his room. Oxygen was being administered at 4 l/min via nasal cannula, and there was no oxygen sign on his door indicating oxygen in use. 675084 Page 4 of 19 675084 06/04/2025 Trinity Nursing & Rehab of Granbury 600 Reunion Court Granbury, TX 76048

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 06/03/2025 at 9:25 a.m., Resident #32 was sitting in his room in wheelchair and the oxygen concentrator was on and being administered to resident at 4 l/min via nasal cannula. Resident #25 Review of Resident #25's electronic face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses to include: brain bleed, prostate cancer, and dementia. Review of Resident #25's quarterly MDS dated [DATE] reflected: BIMS score of 11 which indicated moderate cognitive impairment. Further review of the MDS reflected resident was not on hospice services. Review of Resident #25's comprehensive care plan initiated 12/10/2024 reflected: Problem: Terminal Care (Hospice) .Approach: Pain management, Comfort measures. Review of Resident #25's electronic physicians reflected: Admit to Hospice diagnosis heart disease, dated 05/29/2025 and Admit to Hospice, dated 12/10/2024 and discontinued 05/29/2025. Resident #21 Review of Resident #21's electronic face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses to include: urinary tract infection, anxiety, and dementia. Review of Resident #21's quarterly MDS dated [DATE] reflected: BIMS score of 11 which indicated moderate cognitive impairment. Further review of the MDS reflected resident was not on hospice services. Review of Resident #21's comprehensive care plan initiated 10/10/2024 reflected: Problem: resident is on Hospice .Approach: Hospice will follow resident's needs; resident's rights will be respected. Review of Resident #21's electronic physicians reflected: Admit to Hospice diagnosis degeneration of the brain, dated 05/27/2025 and Admit to Hospice, dated 01/09/2025 and discontinued 05/27/2025. Resident #39 Review of Resident #39's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: heart failure, anxiety, and diabetes. Review of Resident #39's Quarterly MDS dated [DATE], revealed a BIMS score of 13 which indicated no cognitive impairment. Review of Section N: Medications revealed Resident #39 was not receiving anti-anxiety medication. Review of Resident #39's Comprehensive Care Plan last revised 05/30/2025 revealed no evidence of resident medication for anxiety. Review of Resident #39's electronic Physicians Orders revealed: hydroxyzine tablet; 10 mg; amt: 1 tab; oral Special Instructions: 1 tab at bedtime prn or 2 as tolerated/needed At Bedtime for anxiety, start date 03/11/2025 discontinued 05/29/2025 and hydroxyzine tablet; 10 mg; amt: 1 tab; oral 675084 Page 5 of 19 675084 06/04/2025 Trinity Nursing & Rehab of Granbury 600 Reunion Court Granbury, TX 76048

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Special Instructions: 1 tab at bedtime prn or 2 as tolerated/needed At Bedtime start date 05/29/2025 with no stop date. Review of Resident #39's May 2025 MAR revealed 12 doses of hydroxyzine was administered. Review of Resident #39's June 2025 MAR up until 06/03/2025, revealed 3 doses of hydroxyzine was administered. During an interview on 06/04/25 at 03:17 PM, the MDS Coordinator stated anyone receiving hospice services should have been claimed on the MDS. She stated anyone receiving oxygen or taking anti-anxiety medications should have been claimed on the MDS. She stated she just started in May and these MDS were completed prior to that. During an interview on 06/04/25 at 03:31 PM, the DON stated he was responsible for ensuring that the MDS's were completed accurately. He stated they were completed by the MDS Coordinator and then reviewed by him. He stated the hospice, and the oxygen just must have been missed. He stated the facility did not have an MDS policy, the facility follows the RAI. 675084 Page 6 of 19 675084 06/04/2025 Trinity Nursing & Rehab of Granbury 600 Reunion Court Granbury, TX 76048

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents were provided respiratory care received care consistent with professional standards of practice for 1 of 18 residents (Resident #32) and 1 of 1 oxygen storage room reviewed for oxygen administration. Residents Affected - Few 1. The facility failed to post No Smoking sign in resident doorway for Resident #32 on 06/02/2025 & 06/03/2025 who used oxygen. 2. The facility failed to post No Smoking sign on doorway for room that oxygen was stored on 06/02/2025. These failures could place residents at risk of people not being notified of no smoking in oxygen storage or oxygen in use and prohibit smoking in any room, ward, or compartment where oxygen was in use or stored. Findings included: Resident #32 Record review of Resident #32's electronic face sheet dated 06/03/2025 reflected the resident was a [AGE] year-old male originally admitted on [DATE] and most recently re-admitted on [DATE] with diagnoses that included: fusion of spine (surgery to fuse spine), quadriplegia (loss of motor and sensory function in all limbs and the trunk), weakness, pneumonia (infection in the lungs), and chronic obstructive pulmonary disease (disorder that effects air flow in and out of the lungs). Record review of Resident #32's quarterly MDS assessment dated [DATE] reflected: BIMS score of 13 meaning his cognition was intact. Further review of MDS reflected the resident was not on oxygen therapy. Record review of Resident #32's care plan with start date of 12/11/2024 reflected: Problem: [resident name] has an as needed oxygen therapy order related to emphysema/COPD and personal history of smoking .Approach: Administer oxygen at as needed 1-4 l/min via nasal cannula. Observe oxygen precautions. Record review of Resident #32's physician order dated 07/30/2024 reflected oxygen to be administered via nasal cannula as needed at 1-4 l/min for quadriplegia (loss of motor and sensory function in all limbs and the trunk). Record review of Resident #32's progress note dated 05/21/2025 reflected day one of three after roommate change, seems to be tolerating well so far. During an observation on 06/02/2025 at 11:32 a.m., Resident #32 was sitting up in a wheelchair in his room. Oxygen was being administered at 4/l/min and there was no oxygen sign on his door indicating oxygen in use. During an observation on 06/03/2025 at 9:25 a.m., Resident was sitting in his room in his wheelchair and his oxygen concentrator was on. 675084 Page 7 of 19 675084 06/04/2025 Trinity Nursing & Rehab of Granbury 600 Reunion Court Granbury, TX 76048

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 06/02/2025 at 10:01 a.m., empty oxygen cylinders and full oxygen cylinders were stored in a building adjacent to the facility. There was no evidence of an oxygen sign on the door to the building which opened to the room where oxygen was being stored. There were 10 empty cylinders and 25 full canisters. During an interview on 06/03/2025 at 10:52 a.m., the ADON stated residents with oxygen being administered should have an oxygen sign on the door to their rooms. She stated Resident #32 had been on oxygen for a while. She stated she felt him moving rooms recently may have led to failure of no sign on his doorway. During an interview on 06/03/2025 at 11:03 a.m., the DON stated all staff were responsible for making sure no smoking signs were posted outside of resident's rooms. He stated he, the ADON, and the ADMN monitored that appropriate oxygen signs were posted outside of the resident's rooms twice a week. He stated that the resident moving rooms may have led to failure of sign not being posted outside of his room. He stated not having an oxygen sign could be hazardous and may not alert people that oxygen was being used in the room. During an interview on 06/03/2025 at 11:07 a.m., the ED stated she did not know why oxygen in use sign was not posted outside of Resident #32's room. She stated not posting could lead to people not knowing that oxygen was in use inside of the room. She stated she expected that oxygen storage area to have oxygen sign in place on the door, but she never thought of placing a sign on the door leading to where oxygen was stored in building adjacent to facility. She stated not having signs were a safety hazard and would lead to not alerting people that oxygen was stored in that area. During an interview on 06/03/2025 at 12:36 p.m., the RNC stated her expectation would be that areas that store oxygen or oxygen was used, would have a sign outside the door notifying people that oxygen was in use or being stored. She stated the ADMN and DON were responsible for making sure signs were posted when corporate was not in the building. She stated she expected for staff to follow policies about oxygen use and storage. She stated she felt the sign on Resident #32's room could have been removed by another resident or had fallen off the door. She stated not having signs posted could lead to people not knowing that oxygen was in use or being stored. Record review of the facility policy's titled Resident Smoking Policy with no date reflected: No smoking signs will be maintained on doors or gates where oxygen is used or stored. Record review of the facility policy's titled Fire Safety and Prevention with revision date November 2021 reflected: Use visible 'No Smoking' signs where oxygen is stored or being administered. 675084 Page 8 of 19 675084 06/04/2025 Trinity Nursing & Rehab of Granbury 600 Reunion Court Granbury, TX 76048

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based upon observation and interview, the facility failed to ensure staffing information was posted in a prominent place readily accessible to residents and visitors for 1 (06/02/2025) of 3 days reviewed for nursing services and postings. Residents Affected - Many The facility failed to post in a prominent place the current number of licensed and unlicensed nursing staff on 06/02/2025. This failure could place residents, their families, and visitors at risk of not having access to information regarding staffing and facility census. Findings include: During an observation on 06/02/2025 at 9:53 a.m., daily nursing staffing posted across from nurses' station was dated 05/28/2025. During an observation on 06/02/2025 at 1:24 p.m., daily nursing staffing posted across from nurses' station was dated 05/28/2025. During an interview on 06/03/2025 at 9:40 a.m., the DON stated nurse staffing should be posted daily. He stated he was responsible for posting nurse staffing. He stated nurse staffing posting was not posted daily since 5/28/2025 because it slipped his mind. He stated that if any resident or visitor wanted to know the staffing, they could look in a binder at the nurses' station. He stated he felt no negative impact from not posting had occurred. During an interview on 06/03/2025 at 9:41 a.m., the ADMN stated the DON was responsible for posting daily nurse staffing. She stated she monitored that the nurse staffing was posted. She stated she did not know why it had not been posted daily since 05/28/2025 until 06/03/2025. She stated the negative effect of not posting would be that visitors would not have the nursing staff hours for that day. Review of the facility's policy titled Staffing with revision date of 09/28/2023 reflected: Staffing levels for direct care staffing are updated each shift and posted in a public area. 675084 Page 9 of 19 675084 06/04/2025 Trinity Nursing & Rehab of Granbury 600 Reunion Court Granbury, TX 76048

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 store all drugs and biologicals in locked compartments and to permit only authorized personnel to have access to 2 (West Hall medication cart and East Hall medication cart) of 4 medication carts reviewed for pharmacy services. The facility failed to ensure the [NAME] Hall and East Hall medication carts, with prescription medications and biologicals, were secured while unattended. This failure could place residents at risk of harm or decline in health due to lack of potency of supplies, medications/biologicals or misappropriation of medications, or drug diversions. The findings included: During an observation on 06.02.2025 at 10:01 AM, the [NAME] Hall Medication cart had prescription heart medications (amiodarone, amlodipine, metoprolol), prescription depression medications (trazodone), prescription diuretics (metolazone), prescription antinausea (meclizine, ondansetron), prescription diabetes medications (glucagon, insulin), prescription inhalation medications (albuterol, ipratropium bromide, budesonide), prescription anti-yeast medication. (nystatin powder and cream), OTC pain medication (aspirin, Tylenol), OTC constipation medication (MiraLAX). During an observation on 06.02.2025 at 11:28 AM East Hall Medication cart had prescription heart medications (amiodarone, amlodipine, metoprolol), prescription depression medications (trazodone), prescription diuretics (metolazone), prescription antinausea (meclizine, ondansetron), prescription diabetes medications (glucagon, insulin), prescription inhalation medications (albuterol, ipratropium bromide, budesonide), prescription anti-yeast medication. (nystatin powder and cream), OTC pain medication (aspirin, Tylenol), OTC constipation medication (MiraLAX). During an observation on 06.02.2025 at 10:01 AM medication cart on [NAME] Hall was unlocked and unattended for 15 minutes. There were no residents in the hall. During an observation on 06.02.2025 at 11:28 AM medication cart on East Hall was unlocked and unattended for 15 minutes. There were no resident in the hall. 675084 Page 10 of 19 675084 06/04/2025 Trinity Nursing & Rehab of Granbury 600 Reunion Court Granbury, TX 76048

F 0761 Level of Harm - Minimal harm or potential for actual harm During an interview on 06.02.2025 at 10:05 AM, LVN A stated the medication cart (West Hall medication cart) should not have been left unlocked and unattended. LVN A stated residents could get medications that did not belong to them, and this could possibly cause harm to the resident. LVN A stated she had been trained when she was hired on use and medication carts and the keep it locked when not in use by the DON. LVN A stated she just got busy and forgot to lock the medication cart. Residents Affected - Some During an interview on 06.02.2025 at 11:30 AM, RN B stated the medication cart (East Hall medication cart) should be locked when not in use or in line of sight. RN B stated if the medication cart was not locked, other people or residents could take something out of the cart that they did not need. RN B stated this could cause a resident to possibly take a medication not intended for them. RN B stated if a resident took a medication not intended for them, it could possibly cause a health issue for that resident. RN B stated that she left the medication cart to get a resident some ice. RN B stated she had been trained on the use of the medication cart when she was hired by DON. During an interview on 06.04.2025 at 2:49 PM, the DON stated the medication carts should have been locked when not in use. The DON stated the harm could be if a resident took a medication off the cart that was not for them, it could cause an adverse reaction. The DON stated she was not sure why this occurred. The DON stated she and the ADMIN made rounds in the morning and several times a day and check to see the medication carts are locked if not in use. The DON stated nurses and medication aides are trained on hire and PRN, on the use of medication carts. Review of the facility's undated policy titled: Security of Medication Cart The medication cart shall be secured during medications passes. Policy Interpretation and Implementation 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry . Medication carts must be securely locked at all times when out of the nurse's view. 675084 Page 11 of 19 675084 06/04/2025 Trinity Nursing & Rehab of Granbury 600 Reunion Court Granbury, TX 76048

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that each resident received food that is palatable, attractive, and at a safe and appetizing temperature for 1 (Resident #5) of 110 residents tested for nutritive value, flavor, and appearance: Residents Affected - Few The facility failed to provide palatable food served that was palatable and attractive to Residents #5, during lunch on 06/02/2025. Resident #5 received gravy on his hamburger patty. This failure could affect the residents who ate food from the facility kitchen by placing them at risk of poor food intake and/or dissatisfaction of the meals served. The findings included: Record review of Resident #5's face sheet dated 06/04/2025 revealed a [AGE] year-old male admitted on [DATE] with most recent readmission on [DATE] with the following diagnoses Heart failure, high blood pressure, renal failure and type 2 diabetes. Record review of Resident #5's Quarterly MDS assessment dated [DATE] revealed, Section C- Cognitive Patterns revealed Resident #5 had a BIMS score of 14 (meaning cognitively intact). Record review of Resident #5's dietary preferences dated 06/21/2023 revealed Resident #5 disliked gravy. During an observation and interview on 06/02/2025 at 12:40 PM, during the lunch meal service, the Dietary Aide told the [NAME] Resident #5 had no gravy written on his meal ticket. The [NAME] stated she did not know what to do because she had put all the meat patties into the gravy. The [NAME] placed the gravy covered patty on the plate and the plate was covered and served out of the kitchen.During an observation and interview on 06/02/2025 at 1:20 PM, Resident #5 received gravy on his steak after requesting no gravy. Resident #5 stated he only got one meat patty and he was supposed to receive double protein. Resident #5 stated it upset him because his meals were always messed up. Resident #5 stated that he had written no gravy on his ticket that morning, and the kitchen still got it wrong. During an interview on 06/02/2025 at 2:50 PM, the DM stated her expectation was residents' likes and dislikes should have been followed. The DM stated the dietary aides, cooks, and herself were responsible to ensure residents' likes and dislikes were met. The DM stated what led to failure of not meeting Resident # 5's dislikes was she and the cook were trying to bring the meat back up to temperature and added the gravy to all of the meat patties. The DM stated she should have told the cook to keep some of the patties separate from the gravy. During an interview on 06/04/25 at 3:17 PM, the ADMN stated her expectation was that residents' likes and dislikes were honored. The ADMN stated the cooks, nurses, and the DM were responsible to ensure residents' likes and dislikes were honored. The ADMN stated the effect on residents could have been their preferences not being honored which could have led to residents not eating. The ADMN stated what led to the failure was new staff and lack of training. 675084 Page 12 of 19 675084 06/04/2025 Trinity Nursing & Rehab of Granbury 600 Reunion Court Granbury, TX 76048

F 0804 Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy titled Food and Nutrition Services dated September 2021 revealed: Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. Residents Affected - Few 675084 Page 13 of 19 675084 06/04/2025 Trinity Nursing & Rehab of Granbury 600 Reunion Court Granbury, TX 76048

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. 1. The facility failed to ensure that spoiled food items were disposed of properly. 2. The facility failed to ensure foods were labeled properly. 3. The facility failed to ensure that food items were disposed of properly. 4. The facility failed to ensure cans that were dented were removed from food storage. 5. The facility failed to ensure staff wore beard and hair coverings, that secured all hair. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation and interview on 06/02/2025 between 9:30 AM and 9:50 AM of the kitchen revealed Dietary Aide was wearing a hair net that failed to have all hair covered, and dietary aide was not wearing a beard covering over his beard. The Dietary Aide stated he was new and was not told he needed to wear a covering over his beard. The Dietary Aide stated he did not realize he did not have all his hair restrained in his hair covering. Further observation of kitchen revealed: Refrigerator: 1. 1 package of salad mix out of the original container that was not labeled with a use by date. 2. 1 package of lettuce out of the original container that was not labeled with a use by date. 3. 1 package of ham out of the original container that was labeled with a use by date. 4. 1 metal container covered in foil that contained gravy, that was hot to touch. 5. 1 metal container covered in foil that contained oatmeal, that was hot to touch. 675084 Page 14 of 19 675084 06/04/2025 Trinity Nursing & Rehab of Granbury 600 Reunion Court Granbury, TX 76048

F 0812 Level of Harm - Minimal harm or potential for actual harm The Dietary Aide took the temperature of the gravy when it was removed from the refrigerator the temperature of gravy was 140 degrees and the oatmeal temperature was 130 degrees. The Dietary Aide stated he did not put them in the refrigerator and did not know why they were in the refrigerator. The Dietary aide stated he did not know the cooling process. Residents Affected - Some During an observation on 06/02/25 between 9:55 AM to 10:10 AM of the storage building revealed: Dry Storage: 1. 3 unopened boxes of bran flakes cereal with a use by date of 04/19/2025 2. 1 can of chicken noodle soup that was dented. 3. 1 can of cream of mushroom soup that was dented. 4. 1 can of solid packed apples that was dented. 5. 4 bags of tortilla chips out of the original container not labeled with a description or a date. Freezer: 1. 15 packages of vegetables out of the original container that were not labeled with a use by date. During an interview on 06/02/2025 at 11:30 AM, the DM stated she had put the gravy and the oatmeal in the refrigerator when she saw state come in the building. The DM stated she had gotten nervous and was trying to make sure the kitchen looked clean. The DM stated the gravy and oatmeal were too hot to be put into the refrigerator. The DM stated the gravy and oatmeal needed to be cooled to 70 degrees before putting into the refrigerator. The DM stated it was the cooks' and the DM's responsibility to ensure food was cooled prior to placing in the refrigerator. The DM stated it was ultimately her responsibility. The DM stated the effect on residents could have been residents could have gotten sick. The DM stated what led to failure was her being overwhelmed that state was in the building. The DM stated she did not realize male staff needed to wear coverings over their beards. The DM stated staff needed to make sure all their hair was contained in a hair net. The DM stated she did not realize that Dietary Aide did not have all his hair in the hair covering. The DM stated her expectation was staff have all hair covered properly per policy. The DM stated staff were responsible to ensure they used hair and beard coverings. The DM stated she was ultimately responsible to ensure that staff used hair and beard coverings properly. The DM stated what led to failure was she overlooked and 675084 Page 15 of 19 675084 06/04/2025 Trinity Nursing & Rehab of Granbury 600 Reunion Court Granbury, TX 76048

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some assumed it was good enough. The DM stated the affect on residents could have been hair in a resident's food. The DM stated food should have been labeled with a receive date, an open date and a use by date. The DM stated she did not realize the frozen vegetables needed a use by date on them, she assumed there was a manufacture date on each package. The DM stated all staff who stocked food or opened food were responsible to label food. The DM stated she was ultimately responsible for ensuring food was labeled. The DM stated residents could have gotten sick if receiving food that was spoiled or out of date. The DM stated she monitored food storage by making rounds each morning. The DM stated what led to the failure was oversight on her part and being overwhelmed with state in the building. During an interview on 06/04/2025 at 3:17 PM, the ADMN stated her expectation was dietary staff needed to follow the kitchen policies. The ADMN stated the DM and herself were responsible to ensure policy was being followed in the kitchen. The ADMN stated she and the DM should have been making rounds in the kitchen to ensure policy was being followed. The ADMN stated residents could have been exposed to food borne illness or cross contamination. The ADMN stated what led to failures the DM being new and was still learning. Record review of the facility's policy titled, Cooling and Reheating Foods dated 2018, revealed Chill methods place food in 2-inch-deep pans, chill from 140 degrees to 70 degrees in two hours. Record review of the facility's policy titled, Employee Sanitation dated 2018, revealed Employee Cleanliness Requirements .Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces. Record review of the facility's policy titled, Food Storage dated 2018, revealed To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes . All containers by be labeled and dated. Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 06/04/2025 revealed: 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; (3) An accurate declaration of the net quantity of contents; (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD 675084 Page 16 of 19 675084 06/04/2025 Trinity Nursing & Rehab of Granbury 600 Reunion Court Granbury, TX 76048

F 0812 source is already part of the common or usual name of the respective ingredient. Level of Harm - Minimal harm or potential for actual harm (6) Except as exempted in the Federal Food, Drug, and Cosmetic Act § 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. Residents Affected - Some (7) For any salmonid FISH containing canthaxanthin or astaxanthin as a COLOR ADDITIVE, the labeling of the bulk FISH container, including a list of ingredients, displayed on the retail container or by other written means, such as a counter card, that discloses the use of canthaxanthin or astaxanthin. Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date. 675084 Page 17 of 19 675084 06/04/2025 Trinity Nursing & Rehab of Granbury 600 Reunion Court Granbury, TX 76048

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 3 (Resident #8, Resident #25, and Resident #40) of 18 residents reviewed for hospice services. 1. The facility failed to maintain required hospice forms and documentation, that included certificate of terminal illness to ensure that the needs of the resident were addressed and met 24 hours per day to ensure Resident #8, Resident #25, and Resident #40 received adequate end-of-life care. 2. The facility failed to have a communication process, including how the communication will be documented between the facility and the hospice provider, to ensure that the needs of the resident were addressed and met 24 hours per day and to have a physician certification and recertification of the terminal illness for Resident #8, Resident #25, and Resident #40. This failure could place the residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. The findings included: Resident #8 Review of Resident #8's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: anxiety, depression, and schizoaffective disorder. Review of Resident #8's quarterly MDS assessment dated [DATE], revealed a BIMS score of 11 which indicated moderate cognitive impairment. Review of Section O: revealed Resident #8 was on hospice care. Review of Resident #8's Comprehensive Care Plan last revised 04/03/2025, revealed: Problem: Resident is on Hospice .Approach .Report decline in condition to hospice agency. Review of Resident #8's electronic Physicians Orders revealed: Admit to Hospice diagnosis moderate protein calorie malnutrition, dated 05/29/2025 and Admit to Hospice, dated 03/20/2025 and discontinued 05/29/2025. Review of Resident #8's clinical records revealed no evidence of the required hospice forms and documentation, that included certificate of terminal illness or any form of communication between the facility and the hospice provider for Resident #8. Resident #25 Review of Resident #25's electronic face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnosis to include: brain bleed, prostate cancer, and dementia. 675084 Page 18 of 19 675084 06/04/2025 Trinity Nursing & Rehab of Granbury 600 Reunion Court Granbury, TX 76048

F 0849 Level of Harm - Minimal harm or potential for actual harm Review of Resident #25's quarterly MDS dated [DATE] reflected: BIMS of 11 which indicated moderate cognitive impairment. Further review of MDS reflected resident was not on hospice services. Review of Resident #25's comprehensive care plan initiated 12/10/2024 reflected: Problem: Terminal Care (Hospice) .Approach: Pain management, Comfort measures. Residents Affected - Some Review of Resident #25's electronic physicians reflected: Admit to Hospice diagnosis heart disease, dated 05/29/2025 and Admit to Hospice, dated 12/10/2024 and discontinued 05/29/2025. Review of Resident #25's clinical records revealed no evidence of the required hospice forms and documentation, that included certificate of terminal illness or any form of communication between the facility and the hospice provider for Resident #25. Resident #40 Review of Resident #40's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: kidney disease, depression, and renal failure. Review of Resident #40's quarterly MDS dated [DATE], revealed a BIMS score of 10 which indicated moderate cognitive impairment. Review of Section O: revealed Resident #40 was on hospice care. Review of Resident #40's Comprehensive Care Plan last revised 05/30/2025, revealed: Problem: Resident requires Hospice .Approach .Report decline in condition to hospice agency. Review of Resident #40's electronic Physicians Orders revealed: Admit to Hospice, dated 05/27/2025 and Admit to Hospice, dated 03/06/2025 and discontinued 05/27/2025. Review of Resident #40's clinical records revealed no evidence of the required hospice forms and documentation, that included certificate of terminal illness or any form of communication between the facility and the hospice provider for Resident #8. During an interview on 06/04/25 at 03:00 PM, the DON stated that communication between hospice staff and facility staff was done verbally, but the facility did not have any written documentation of communication. He stated he was not aware that communication needed to be documented. He stated he did not know why the facility did not have the certifications of terminal illness on file for these 3 residents. Review of the facility's policy titled, Hospice Program, revised July 2017, revealed in part: Policy Statement: Hospice services are available to residents at the end of life. Policy Interpretation and Implementation . 10. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual residents' needs. These responsibilities include the following .d. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day .12. Our facility is responsible for a. Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process. B. Communicating with hospice representatives and other healthcare providers participating on the provision of care .d. Obtaining the following information from the hospice . 3.) Physician certification of the terminal illness specific to each resident. 675084 Page 19 of 19