Granbury Care Center

In the surveyor’s words

From the most serious findings on record at Granbury Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Feb 21, 2024

  Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 2 (Resident #1 and Resident #2) of 10 residents reviewed for multiple falls. The facility failed to implement a system for identifying fall patterns and implementing interventions to prevent falls that lead to emergency room visits with serious injury on [DATE] and [DATE] for Resident #1 and [DATE] and [DATE] for Resident #2. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 10:25 am. […]

• Immediate jeopardy, isolatedF678Sep 12, 2025

  Based on interview and record review the facility failed to ensure that a resident received CPR in accordance with professional standards of practice for one (Resident #1) of six resident's reviewed for CPR. On [DATE] at 12:20 am, LVN A failed to initiate CPR on Resident #1 who was a full code status. Resident #1 expired on [DATE]. An Immediate Jeopardy was identified on [DATE] at 5:00 pm. The noncompliance began on [DATE] and ended on [DATE]. It was determined to be past non-compliance due to the facility having implemented action that corrected the non-compliance prior to the beginning of the investigation. This failure could affect residents who are full code status and could need CPR by placing them at risk of death. […]

• No harm, potential for more than minimal, widespreadF812Oct 6, 2022

  FACILITY 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. The facility failed to ensure food temperatures were taken prior to being served. The facility failed to ensure that staff utilized proper personal hygiene practices during food preparation. The facility failed to ensure that kitchen staff's mask covered both mouth and nose. These failures could place residents that eat food from the kitchen at risk for food borne illnesses. Findings included: During an observation on 10/06/2022 between 11:45 AM and 1:00 PM revealed: Dietary Aide A getting ice and drinks set up for meal trays. […]

• No harm, potential for more than minimal, widespreadF812Aug 12, 2021

  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. Foods were not sealed and/or labeled properly in dry food storage and refrigerators. 2. Cooks failed to wash hands after touching unsanitary items. 3. Areas in the kitchen were not clean, exposing food and equipment to unsanitary conditions. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. Findings included: In an observation on 08/10/2021 at 9:20 AM of the kitchen with the Dietary Manager (DM) revealed: Refrigerator #1 1. One Jar of Salad Dressing that was not dated. 2. […]

• No harm, potential for more than minimal, patternF842Jul 30, 2026

  Based on observation, interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 3 of 7 residents (Resident #3, Resident #4, and Resident #6) reviewed for accurate records. 1.The facility failed to have documentation to indicate why Resident #3's medications were not given on 07/15/2026. (Ivermectin and Spinosad), and 07/16/2026 (Spinosad). […]