Health inspection·November 30, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few MAR dated 11/17/2025, 11/19/2025, and 11/20/2025 reflected Midodrine 5 MG oral tablet (low blood pressure) was not signed off given by RN AA record review of Resident #1's MAR dated 11/19/2025 and 11/20/2025 reflected Levothyroxine sodium oral tablet (treats underactive thyroid) 125 MCG was not signed off given by LVN B A record review of Resident #1's MAR dated 11/14/2025 reflected secure catheter with a leg strap/leg band or anchor to minimize catheter related injury and accidental removal or obstruction of urine outflow check placement was not signed off on by LVN BA record review of Resident #1's MAR dated 11/18/2025 and 11/19/2025 reflected secure catheter with a leg strap/leg band or anchor to minimize catheter related injury and accidental removal or obstruction of urine outflow check placement was not signed off on by RN A.A record review of Resident #1's MAR dated 11/14/2025 reflected suprapubic catheter care every shift monitor S/P insertion site for S/S of skin breakdown, pain/discomfort, unusual odor, urine characteristics or secretions catheter pulling causing was not signed off on by LVN B .A record review of Resident #1's MAR dated 11/18/2025 and 11/19/2025 reflected suprapubic catheter care every shift monitor S/P insertion site for S/S of skin breakdown, pain/discomfort, unusual odor, urine characteristics or secretions catheter pulling causing[ tension was not signed off on by RN A.A record review of RN A's written statement dated 11/29/2025 at 6:00 pm stated that on 11/17/2025 , 11/19/2025, and 11/20/2025 she stated she did administer Resident #1 the Midodrine (low blood pressure), Levothyroxine (underactive thyroid), secured the catheter and monitored the insertion site for any complications. RN A stated that she forgot to sign off on them when she had administered. RN A educated to make sure all documentation was completed when the medication was administered.A record review of LVN B written statement dated 11/30/2025 at 10:00 am stated that on 11/13/2025 and 11/14/2025 he statedd he did administer the Levothyroxine (underactive thyroid) and completed the catheter care but forgot to document after completing. LVN B was educated to make sure his documentation was completed when medications and task was done.Attempted to interview RN A on 11/29/2025 at 2:04 pm, 11/30/2025 at 12:05 pm, and 1:38 pm. Voice messages were left and no call back was received by exit date 11/30/2025.Attempted to interview LNV B on 11/29/2025 at 2:15 pm, 11/30/2025 at 12:03 pm, and 1:35 pm. Voice messages were left and no call back was received by exit date 11/30/2025.During an interview with the ADON on 11/29/2025 at 2:07 pm, the ADON stated she was not able to say why RN A and LVN B did not sign off when they completed the task. The ADON stated it was expected for the MAR to be signed off on once administered to show that the medication or treatment was given. The ADON stated by RN A and LVN B not signing off on the MAR it would not have been known if it was given or not. The ADON stated that if it was not signed off on it would indicate that it did not happen and depending on the medication could result in further illness.During an interview with the ADM on 11/30/2025 at 1:40 pm, the ADM stated it was expected for RN A and LVN B to have signed off on the MAR to ensure documentation was entered timely and accurately. The ADM stated if the MAR was not signed off on it would have indicated that it did not happen and may cause a decline in health. Record review of the facility's, undated, policy titled medication and treatment administration reflected It is the policy of this facility that medications and treatments are administered only upon the clear, complete, and prescribed by lawfully authorized provider. Verbal orders are received only by licensed nurses or pharmacists and confirmed by electronic signature by the prescriber. Documentation of the Medication. Each medication order is documented in the resident's medication Administration Record (MAR) with the date, time, and signature of the person administering the medication''. [KS1]The layperson does not know what Point Click Care is - please use plain language here [KS2]There's no review of the MAR/TAR for 11/17 [KS3]This does not really make sense [KS4]Are there words missing? [CW5]Tension added [KS6]How do we know RN A administered Levothyroxine on 10/20? Was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676220 If continuation sheet Page 2 of 3 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 676220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Granite Mesa Health Center 1401 Max Copeland Dr Marble Falls, TX 78654 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete this a medication error instead of a documentation error? [CW7]The statement the RN A was it was giving but just not signed off on this documentation and not med error [KS8]How do we know RN A administered Levothyroxine on 11/13? Was this a medication error instead of a documentation error? [CW9]The statement the RN A was it was giving but just not signed off on this documentation and not med error [KS10]How do we know RN A administered Levothyroxine on 11/13? Was this a medication error instead of a documentation error? [CW11]The statement the RN A was it was giving but just not signed off on this documentation and not med error [KS12]How do we know LVN B administered Levothyroxine on 11/19 and 11/20? Was this a medication error instead of a documentation error? [CW13]The statement the LVN B was it was giving but just not signed off on this documentation and not med error [KS14]How do we know LVN B checked the catheter placement on 11/14? Was this a failure to provide care or a failure to document? [CW15]Written statement documentation error [KS16]How do we know RN A checked the catheter placement on 11/18? Was this a failure to provide care or a failure to document? [CW17]Written statement document error [KS18]It seems like there are missing words after causing [KS19]How do we know LVN B performed catheter care on 11/14? Was this a failure to provide care or a failure to document? [CW20]The statement the LVN B was it was done but just not signed off on this documentation and not med error failure to document [KS21]How do we know RN A performed catheter care on 11/18? Was this a failure to provide care or a failure to document? [CW22]The statement the RN A was it was done but just not signed off on this documentation and not med error [KS23]It seems like there are missing words after causing [CW24]tension [KS25]There is no review of the MAR/TAR for 11/17 [KS26]There's no review of the MAR saying she didn't administer the Midodrine on 11/19 [CW27]added [KS28]There's no review of the MAR saying LVN B didn't administer the Levothyroxine on 11/13. Our review of the MAR for 11/13 says Levothyroxine was not signed off by RN A. [KS30]There's no review of the MAR saying LVN B didn't administer the Levothyroxine on 11/14. The only MAR review we have for 11/14 was about catheter placement/care. [CW31]Not 11/14 Event ID: Facility ID: 676220 If continuation sheet Page 3 of 3