Health inspection·December 4, 2023

F 0755 Level of Harm - Immediate jeopardy to resident health or safety Further review reflected additional orders dated 08/15/2023 stating, requiring approval from nephrologist for loading dose of Acyclovir. Please give attached loading prescription to Nephrologist for approval to be started once approved., Further review revealed Resident #1's Acyclovir medication schedule proposed from Ophthalmologist was as follows: Sunday: Morning 200 MG-8AM, Night 200 MG-8PM Residents Affected - Some Monday: 200 MG-8AM, Night 400 MG-After Dialysis Tuesday: 200 MG-8AM, Night 200MG-8PM Wednesday: 200 MG-8AM, Night 400 MG-After Dialysis Thursday: 200 MG-8AM, Night 200MG-8PM Friday: Wednesday: 200 MG-8AM, Night 400 MG-After Dialysis Saturday: 200 MG-8AM, Night 200MG-8PM Review of Resident #1's Orders, no date, reflected an order for Acyclovir Oral Capsule, Directions to Give 200 MG by mouth two times a day every Tue (Tuesday), Thu (Thursday), Sat (Saturday), Sun (Sunday) for eyes, ordered 08/31/2023, start 08/31/2023. Further review reflected a second order for Acyclovir Oral Capsule 200 MG (Acyclovir), Direction to Give 200 MG by mouth one time a day every Mon (Monday), Wed (Wednesday), Fri (Friday) for eyes AND Give 400 MG by mouth in the evening every Mon (Monday), Wed (Wednesday), Fri (Friday) for eyes., ordered 08/31/2023, start 09/01/2023. Further review of Resident #1's orders reflected an order for Trifluridine Ophthalmic Solution 1% (Trifluridine), Directions Instill 1 drop in right eye every 3 hours for Herpes Infection of the right eye 1 drop right eye 9x (9 times) a day, ordered 07/18/2023, start 07/19/2023. Review of Resident #1's MAR, dated 11/30/2023, reflected no documentation that Resident #1 received Acyclovir capsules on: 10/16/2023 Monday 18:00 (06:00 p.m.) 10/31/2023 Tuesday 20:00 (08:00 p.m.) 11/02/2023 Thursday 08:00 (8:00 a.m.), 20:00 (8:00 p.m.) 11/04/2023 Saturday 08:00 (8:00 a.m.), 20:00 (8:00 p.m.) 11/05/2023 Sunday 08:00 (8:00 a.m.), 20:00 (8:00 p.m.) Review of Resident #1's MAR, dated 11/30/2023, reflected no documentation that Resident #1 received Trifluridine on: 07/23/2023 Sunday 06:00 (06:00 a.m.) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455554 If continuation sheet Page 2 of 20 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 455554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coral Rehabilitation and Nursing of McGregor 414 Johnson Dr MC Gregor, TX 76657 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 0755 07/27/2023 Thursday 06:00 (06:00 a.m.), 18:00 (06:00 p.m.) Level of Harm - Immediate jeopardy to resident health or safety 08/02/2023 Wednesday 21:00 (09:00 p.m.) Residents Affected - Some 08/05/2023 Saturday 06:00 (06:00 a.m.) 08/03/2023 Thursday 00:00 (12:00 a.m.), 03:00 (03:00 a.m.) 08/09/2023 Wednesday 06:00 (06:00 a.m.) 08/11/2023 Friday 06:00 (06:00 a.m.) 08/12/2023 Saturday 18:00 (06:00 p.m.) 08/18/2023 Friday 06:00 (06:00 a.m.) 08/21/2023 Monday 06:00 (06:00 a.m.), 18:00 (06:00 p.m.) 08/27/2023 Sunday 06:00 (06:00 a.m.) 09/12/2023 Tuesday 21:00 (09:00 p.m.) 09/13/2023 Wednesday 00:00 (12:00 a.m.), 03:00 (03:00 a.m.), 06:00 (06:00 a.m.) 09/21/2023 Thursday 21:00 (09:00 p.m.) 09/24/2023 Sunday 06:00 (06:00 a.m.) 09/28/2023 Thursday 21:00 (09:00 p.m.) 09/29/2023 Friday 00:00 (12:00 a.m.), 03:00 (03:00 a.m.), 06:00 (06:00 a.m.) 10/16/2023 Monday 18:00 (06:00 p.m.) 10/22/2023 Sunday 15:00 (03:00 p.m.), 18:00 (06:00 p.m.) 10/24/2023 Tuesday 00:00 (12:00 a.m.), 03:00 (03:00 a.m.), 06:00 (06:00 a.m.) 10/25/2023 Wednesday 07:00 (07:00 a.m.) 10/26/2023 Thursday 07:00 (07:00 a.m.) 10/27/2023 Friday 07:00 (07:00 a.m.) 10/28/2023 Saturday 07:00 (07:00 a.m.) 10/29/2023 Sunday 07:00 (07:00 a.m.) 10/30/2023 Monday 07:00 (07:00 a.m.) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455554 If continuation sheet Page 3 of 20 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 455554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coral Rehabilitation and Nursing of McGregor 414 Johnson Dr MC Gregor, TX 76657 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 0755 10/31/2023 Tuesday 07:00 (07:00 a.m.) Level of Harm - Immediate jeopardy to resident health or safety 11/01/2023 Wednesday 07:00 (07:00 a.m.) Residents Affected - Some 11/03/2023 Friday 07:00 (07:00 a.m.) 11/02/2023 Thursday 07:00 (07:00 a.m.) 11/04/2023 Saturday 07:00 (07:00 a.m.) 11/07/2023 Tuesday 07:00 (07:00 a.m.) 11/08/2023 Wednesday 07:00 (07:00 a.m.) 11/09/2023 Thursday 07:00 (07:00 a.m.), 19:00 (07:00 p.m.) 11/10/2023 Friday 07:00 (07:00 a.m.) 11/11/2023 Saturday 07:00 (07:00 a.m.) 11/12/2023 Sunday 07:00 (07:00 a.m.) 11/13/2023 Monday 07:00 (07:00 a.m.) 11/14/2023 Tuesday 07:00 (07:00 a.m.) 11/16/2023 Thursday 07:00 (07:00 a.m.) 11/17/2023 Friday 07:00 (07:00 a.m.) 11/18/2023 Saturday 07:00 (07:00 a.m.) 11/19/2023 Sunday 07:00 (07:00 a.m.) 11/21/2023 Tuesday 07:00 (07:00 a.m.) 11/22/2023 Wednesday 07:00 (07:00 a.m.) 11/25/2023 Saturday 07:00 (07:00 a.m.) 11/27/2023 Monday 07:00 (07:00 a.m.) 11/28/2023 Tuesday 07:00 (07:00 a.m.) Review of Resident #1's Ophthalmologist records, dated 11/28/2023, reflected an exam performed revealed Ocular Adnexa (parts of the body that are connected to the surrounded eye) and Anterior Segment (eye cavity, front-most region of eye, includes the cornea, iris, and lens.) OD (oculus [NAME]-right eye), noted 2+Descemet Folds (manifestation of edema or inflammation in the cornea), Central Epithelial (body tissue) Defect with Rolled Edges, 1+Fluress Staining of Cornea. Procedure Prokera Slim (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455554 If continuation sheet Page 4 of 20 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 455554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coral Rehabilitation and Nursing of McGregor 414 Johnson Dr MC Gregor, TX 76657 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 0755 (amniotic membrane that is thin and clear placed on the surface of the eye damaged tissue while inserted.) Level of Harm - Immediate jeopardy to resident health or safety Interview on 11/30/2023 at 01:29 p.m., Resident #1's Ophthalmologist revealed concerns of Resident #1 receiving her medications for her eye infection. He further stated they had a typed version, of her schedule, of the Acyclovir, because there were concerns Resident #1 was not receiving it. He stated the ophthalmology provider started seeing Resident #1 in July for her right eye. He stated, her vision was somewhat decent, but from then on, her vision decreased. The Ophthalmologist stated that, Resident #1 went from being able to see large letters, to not being able to that all anymore, it (vision) has gotten worse. The Ophthalmologist further stated, It became apparent she (Resident #1) wasn't getting treatment, based on the exams, her (Resident #1) visual acuity has gotten worse. The Ophthalmologist stated that, its 100 percent important for all the orders to be completed, and I want to add that it is extremely important for her (Resident #1) to get the Acyclovir as prescribed and to be given consistently, despite her (Resident #1) history of diabetes, if she (Resident #1) had her consistent treatment, this would have been avoided, due to her (Resident #1) renal dialysis, she was getting less than the usual standard of care for the Acyclovir, therefore its more important to get it as when she gets dialyze the medication is removed from her system. The Ophthalmologist stated that, there was scarring in the cornea, in her (Resident #1) right eye, and we are suggesting corneal transplant. The Ophthalmologist explained, the last exam revealed the back layers, the Descemet folds, is a sign of edema (swelling) and/or infection. The rolled edges listed in her exam mean that the epithelial tissue is trying to grow back due to damage. Residents Affected - Some Interview on 11/30/2023 at 02:46 p.m., Resident #1 stated when she got back from all her doctor's appointments, she gave the discharge orders and changes to her medications to nursing staff. Resident #1 stated there are times she does not have her eye medications for a week. Resident #1 stated that her right eye is the eye that she cannot see out of, and she stated that her vision got worse. Interview on 11/30/2023 at 03:26 p.m., ADON stated that when any resident returns from a specialist or outside provider visit, it was encouraged that residents are to give the discharge orders to the nurse, the nurse updates the orders in the resident's EHR, as prescribed, as instructed, as directed. Staff are to administer medications as instructed and document the process. ADON stated that the facility obtained its medications from an outside pharmacy provider, as ordered, and if medications are not available, staff are to contact the MD or NP and are to follow the procedure communicating with providers, checking the emergency medication kit. No other statement was made on Resident #1's missing medication administration. Interview on 12/01/2023 at 11:42 p.m., the MD stated she was only informed that (Resident #1) did not get her Trifluridine, MD is not aware of the other items related to the missing medication administrations. MD stated that when orders come in from outside providers, they are documented in the resident's EHR and followed. MD is not aware if Resident #1 gave her orders to the nurse, or if the ophthalmologist faxed the orders over, the MD stated there is no set protocol for this type of occasion as residents are encouraged to give their discharge orders from outside providers. Interview on 12/01/2023 at 01:54 p.m., the NP stated she was not aware of the missing medications, and that outside specialist usually do not call us, typically nurses would communicate with her on all items that involve a resident, from changes of conditions to medications not being available. Interview on 12/01/2023 at 2:10 p.m., MA A stated being familiar with Resident #1. MA A stated, if medications are not available, staff notify the resident's nurse, DON, and ADON, and medications can (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455554 If continuation sheet Page 5 of 20 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 455554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coral Rehabilitation and Nursing of McGregor 414 Johnson Dr MC Gregor, TX 76657 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 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some be reordered through the residents EHR, and that I can call pharmacy myself., MA A further stated, we attempt to keep medication filled and re-order medication five to seven days before the medications are expected to run out. MA A added that she was aware that Resident #1's Acyclovir was not available, although she cannot recall the exact time, it had been ordered, and as well as the Trifluridine. MA A stated the residents have these medications for a reason, their conditions, to treat the residents so they may, get better. MA stated that when Resident #1's medications were not available, she did not successfully administer the ordered medications to Resident #1. Interview on 12/01/2023 at 2:32 p.m., LVN A stated that, there are orders for medications, and when residents let us know the orders from outside providers, we placed them in, instructions, frequency, all details of the medications into the resident's EHR system. LVN A stated, to reorder medications, we use the EHR, orders are refilled five to seven days before medications are out to avoid missing medications, and if an event occurs in that there are no medications, we call the pharmacy, the NP or MD, and ask for alternatives. LVN A stated to check the overstock medications and the emergency medication kit. LVN A stated if the procedures for medication administration are not followed, it is detrimental to a resident's health and his or her plan of care. Record review of the facility's Medication: Reordering policy, effective 04/01/2017 and last reviewed 03/22/2023, reflected that, it is the policy of the facility to reorder medications when supply is running low (2 days prior), purpose is to ensure that all meds re available in sufficient quantity to fulfill MD orders. 5. Nurse responsibility, if medications is not received in a timely manner, recalls the pharmacy to obtain estimated delivery time. Notifies nursing supervisor, manager and DNS/ADNS (Director of nursing/Assistant director of nursing). 6. Nurse responsibility, if medication is not available for the specific medication notifies MD/NP to obtain hold order or substitute medication which may be available in emergency stock. Reorders medications form pharmacy through the EMR. Contacts pharmacy to ensure that reorder was received and confirmed estimated delivery time. 7. DNS/ADNS/NM/RNS responsibility, the nursing supervisor/NM or nursing administration will run a random report to ensure that all meds are administered as per MD order. Record review of the facility's Administering Medications policy, revised April 2019, reflected, Policy statement that Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 22. The individual administering the medication initials the resident's MAR in the appropriate line after giving each medication and before administering he next ones. The ADM was notified on 12/01/2023 at 04:17 p.m., that an IJ situation was identified due to the above failures and the IJ template was provided. The plan of Removal was accepted on 12/03/2023 at 09:36 a.m., and included: Immediate action: 12/02/2023 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455554 If continuation sheet Page 6 of 20 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 455554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coral Rehabilitation and Nursing of McGregor 414 Johnson Dr MC Gregor, TX 76657 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 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some The resident affected by this deficiency (F755), was assessed and noted to be stable as of 12/02/2023. An audit of this resident's current list of medications was performed by the Administrator on 12/02/2023 and revealed that all current medications for this resident were delivered and are available in the facility. The administration of the resident medications was assigned to the charge nurse on the hall. The am and pm doses were adjusted so they would align with her blood sugar checks. An audit of this resident's medication administration record (MAR), conducted on 12/02/2023 by the administrator, revealed that all current ordered medications are being administered according to the instructions on the physician orders. Training of staff and audits of all medication were initiated by the Administrator and ADON on 12/02/2023 Identification of others: All residents have the potential to be impacted by this deficient practice. The Administrator conducted an audit of the medication list of all residents within the facility on 12/02/2023 and found that all medications are available within the facility. The Administrator conducted a medication administration record (MAR) audit for all residents in the facility on 12/02/2023 to ensure accuracy of medication administration and found that all ordered medications were being administered to all residents accurately according to physician's orders. No other resident was found to be affected. The Administrator has started an education for all Nursing staff on Medication Administration with a focus on ensuring accuracy, expected completion date is 12/2/23. All staff that administer medications and receive orders have been educated as of 12/02/2023. The Regional Nurse Consultant provided an education on conducting medication list audits to the administrator, Director of Nursing, and ADON on 12/02/2023. The Regional Nurse Consultant provided and education on conducting MAR audits to the administrator and Director of Nursing on 12/02/2023. The Regional Nurse Consultant has updated the facility's procedure for communicating with outside Physicians and Clinics, which includes contacting physicians and confirming orders, on 12/02/2023. The Regional Nurse Consultant has updated the facility's policy on communication, contacting Physicians and confirming orders, on 12/02/2023 to reflect these new changes. The Regional Nurse Consultant has provided education to the administrator, Director of Nursing, and ADON on 12/02/2023, regarding these changes and policy updates. The Regional Nurse Consultant has educated the Administrator, DON and ADON on conducting audits of the facility's communication procedure, including contacting physicians and confirming orders, on 12/02/2023. The administrator has created and audit to monitor compliance to the facility's communication procedure for contacting Physicians and confirming orders. Audits will be conducted by the ADON daily for two weeks, weekly for 2 weeks and monthly for two months. Any negative findings will be reported to the administrator for immediate correction. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455554 If continuation sheet Page 7 of 20 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 455554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coral Rehabilitation and Nursing of McGregor 414 Johnson Dr MC Gregor, TX 76657 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 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some The Administrator and ADON has started an education for all staff on communicating, contacting physicians and verifying orders, expected completion date is 12/02/2023. The administrator has created a MAR audit to monitor for accuracy of medication administration on 12/02/2023. ADON will conduct MAR audits to ensure the accuracy of medication administration, daily for two weeks, weekly for two weeks and monthly for two months. Any negative findings will be taken to the administrator for immediate correction. The DON, or ADON will continue to audit the medication administration in the building on Mondays and Thursday as part of the facility ongoing process to ensure accuracy of medication administration. The results of the new audit process will be reported to the QAPI team. The Medical Director was notified of the deficiency (F755) on 12/01/2023 and an Ad-Hoc QAPI meeting was held on 12/02/2023 to discuss the findings. All findings will be reported to the QAPI team for QAPI. Expected compliance date is 12/02/2023. The Survey Team monitored the Plan of Removal on 12/03/2023 to 12/04/2023: Interview on 12/03/2023 from 04:15 p.m. to 04:17 p.m., CNA A, CNA B and CNA C confirmed they have taken in-services on education administration or missing medications to notify ADM, DON, ADON immediately, stating that if they heard a resident had a medication issue to tell the MA, DON, ADON or the ADM. Interview on 12/03/2023 from 04:20 p.m. to 04:35 p.m., MA A and MA B confirmed they have taken the in-services on medication pass education and education administration/missing medications to notify ADM, DON, ADON immediately. Interview on 12/04/2023 at 10:45 a.m., MA C confirmed in-services on medication pass education and education on administration/missing medications to notify ADM, DON, ADON immediately. MA C stated, when medications are reordered, and the medications are not at the facility in a timely manner, we call the pharmacy, get the nurse, the ADM, DON and ADON involved. MA C stated, we look in the residents' MAR to see what medications are missing, and fax orders to the pharmacy, or order medications through the resident's EHR, and call the pharmacy to check status and estimated time of delivery. MA C confirmed education on checking the facility's overflow medications if missing medications are available. MA C is aware that MD and NP are to be notified by nurses to check for alternative medications. Interview on 12/04/2023 from 10:52 a.m. to 11:09 a.m., the DON and ADON confirmed in-services, education and process of medication administration with a focus on ensuring accuracy, conducting medication list audits and sending audits to ADM, communicating with outside physicians and clinics, contacting physicians and confirming orders, audit to monitor compliance of the facility's communication procedure for contacting physicians and confirming orders. DON and ADON confirmed audits are conducted daily for two weeks, weekly for 2 weeks, and monthly for two months. DON and ADON confirmed that negative are to be reported to the ADM for immediate correction. DON and ADON confirmed process to conduct MAR audits to ensure the accuracy of medication administration daily for two weeks, weekly for two weeks, and monthly for two months. DON and ADON confirmed any negative findings are to be taken to the Administrator for immediate correction. DON and ADON stated that the MD was notified of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455554 If continuation sheet Page 8 of 20 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 455554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coral Rehabilitation and Nursing of McGregor 414 Johnson Dr MC Gregor, TX 76657 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 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some deficiency and Ad-Hoc QAPI meeting was held on 12/02/2023 to discuss findings and provide immediate interventions. DON and ADON stated that the facility has a new for called the missing medication form. The form documents the name of the resident, missing medication, name of nurse notified, time pharmacy called, pharmacy staff name, ETA of medication delivery, and was medication delivered as stated in the ETA of medication delivery. Interview on 12/04/2023 at 11:12 a.m., TS A confirmed an updated process during specialist or outside provider visits, TS A would have outside providers complete a form called a visit summary. The summary is given to the DON, ADON, and charge nurse. Staff stated this form would be used to assure accurate discharge orders are given to the nurse. Interview on 12/04/2023 at 11:38 a.m., MA A stated she took the in-services on medication pass education and education administration/missing medications. MA A stated, If I hear a resident has a medication issue to tell the DON ADON or the ADM. and it is important to follow up on the new process, and the risks of not following the process could negatively affect residents' health and well-being. Interview on 12/04/2023 on 01:09 p.m., the MD stated that an Ad-Hoc QAPI meeting was attended on 12/02/2023 to discuss non-compliance IJ, and plan of intervention. MD stated that there are new processes as well to electronically fax all new orders to her to make sure they are in residents EHR. Interview on 12/04/2023 on 01:11 p.m., the NP stated that all new medication orders will be placed in her care folder to be reviewed and to assure communication is accurate, check all medication, and ensure all new medications are in the residents' EHR. Interview on 12/04/2023 on 01:32 p.m., the ADM stated and confirmed in-services, education, and process of Medication Administration with a focus on ensuring accuracy, conducting medication list audits that are to be sent to her, communicating with outside Physicians and Clinics, which includes contacting physicians and confirming orders, audit to monitor compliance to the facility's communication procedure for contacting Physicians and confirming orders. ADM stated audits will be conducted daily for two weeks, weekly for 2 weeks, and monthly for two months. Any negative findings will be reported to her for immediate correction. ADM stated DON and ADON will conduct MAR audits to ensure the accuracy of medication administration, daily for two weeks, weekly for two weeks, and monthly for two months. Any negative findings will be taken to her for immediate correction. The ADM stated that the MD was notified of the deficiency and an Ad-Hoc QAPI meeting was held on 12/02/2023 to discuss the findings and provide immediate interventions. ADM stated that the facility has a new form, missing medication form, that is used if the medication is unable to be obtained to notify nurse management. The ADM stated the next QAPI meeting is scheduled on 12/18/2023, audits will be discussed to assure accuracy. ADM stated that MA A has been documented of having a corrective action placed in her employee file. Record review on 12/04/2023, reflected medication administration record (MAR) audit for all residents completed. Record review on 12/04/2023, reflected medication administration record (MAR) audit for all residents with no significant findings. Record review on 12/04/2023, reflected orders in Resident #1 EHR, Acyclovir Oral Capsule 200 MG and Trifluridine Drops 9 x daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455554 If continuation sheet Page 9 of 20 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 455554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coral Rehabilitation and Nursing of McGregor 414 Johnson Dr MC Gregor, TX 76657 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 0755 Level of Harm - Immediate jeopardy to resident health or safety Record review on 12/04/2023, reflected medication administration for scheduled Acyclovir and Trifluridine, no medications missed. Record review on 12/04/2023, reflected in-services and education on Medication Administration with a focus on ensuring accuracy, conducting medication list audits to the administrator, education for all staff on communicating, contacting physicians, and verifying orders, and Ad-Hoc QAPI conduced on 12/02/2023. Residents Affected - Some Record review on Communication with Consultants policy, last review 05/28/2023, it is policy of facility to maintain effective communication between members of the care team, including but not limited to MDs, Nurses, Consultants, outside clinics and health care facilities (hospitals, nursing homes, etc.). General information, the License nurse will ensure that a copy of the facility's consultation form, is sent with each resident going for an outside appointment. Will prefill the consult form with the resident's name, DOB and reason for visit, upon return the License nurse will receive and review the returning consultation form, which would not have been completed by the consulting physician, with findings and recommendations/orders where necessary. If the form is not returned, or returned incomplete, the license nurse will reach out to clinic, hospital, or local MD office to obtain recommendations for the target resident, following their appointment, will repeat the information once received to ensure accuracy and completeness, will request a fax copy of this information if possible. Record review on 12/04/2023, reflected a Personnel Action form for MA A, dated 12/02/2023, : failure to obey orders, Remarks: 1. Medication not administered in a timely fashion. 2. OTC not administered. 3. Nurse not notified the medications not available. It is the expectation that all medications will be administer as ordered and within the timeline parameters. Issues with meds (medications) will be reported immediately. Due to severity of actions this is a level 3., signed and dated by ADM on 12/02/2023. The ADM was notified on 12/04/2023 at 2:19 p.m. that the Immediate Jeopardy was lowered. While the IJ was removed on 12/04/2023, the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of the corrective systems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455554 If continuation sheet Page 10 of 20 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 455554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coral Rehabilitation and Nursing of McGregor 414 Johnson Dr MC Gregor, TX 76657 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 (Resident#1) of 8 resident reviewed for pharmaceutical services. Residents Affected - Some The facility failed to follow prescribers' orders and professional standards and principles which apply to professionals providing services for Resident #1's scheduled medications. Resident #1 was not given Acyclovir for a total of 8 times, one post-dialysis dose of 400 MG on 10/16/2023, and seven 200 MG doses from 10/31/2023 through 11/05/2023. Resident #1 was not given Trifluridine a total of 59 times from 7/23/2023 through 11/28/2023, with 22 of the 59 missed Trifluridine doses having been missed in the month of November 2023. This failure resulted in the Resident #1's eye infection not healing effectively, and Resident #1 being considered for corneal transplant. An IJ was identified on 12/01/2023. The IJ Template was provided to the facility on [DATE] at 04:17 p.m. While the IJ was removed on 12/04/2023, the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not Immediate Jeopardy because of the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of discomfort or jeopardizes his or her health and safety. Findings included: Review of Resident #1's face sheet, dated 11/30/2023, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses End Stage Renal Disease, Dependence on Renal Dialysis, and kidney disease. Review of Resident #1's quarterly MDS assessment, dated 09/02/2023, reflected a BIMS of 15 indicating his cognition was intact. Further review revealed her vision was assessed as a 1 indicating impaired vision (sees large print, but not regular print in newspapers/books). Review of Resident #1's care plan, date Initiated: 06/01/2022, revised on: 10/23/2023, with a Target Date: 01/22/2024, reflected a goal that Resident #1 would have no indication of acute eye problems through the review date, and an intervention to arrange consultation with eye care practitioner as required. Review of Resident #1's Ophthalmologist orders and progress notes, dated, 08/14/2023, reflected to continue Trifluridine, 9x (9 times) a day OD (Ocular [NAME]-right eye) without missing at all. Further review reflected additional orders dated 08/15/2023 stating, requiring approval from nephrologist for loading dose of Acyclovir. Please give attached loading prescription to Nephrologist for approval to be started once approved., Further review revealed Resident #1's Acyclovir medication schedule proposed from Ophthalmologist was as follows: Sunday: Morning 200 MG-8AM, Night 200 MG-8PM Monday: 200 MG-8AM, Night 400 MG-After Dialysis (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455554 If continuation sheet Page 11 of 20 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 455554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coral Rehabilitation and Nursing of McGregor 414 Johnson Dr MC Gregor, TX 76657 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 0760 Tuesday: 200 MG-8AM, Night 200MG-8PM Level of Harm - Immediate jeopardy to resident health or safety Wednesday: 200 MG-8AM, Night 400 MG-After Dialysis Residents Affected - Some Friday: Wednesday: 200 MG-8AM, Night 400 MG-After Dialysis Thursday: 200 MG-8AM, Night 200MG-8PM Saturday: 200 MG-8AM, Night 200MG-8PM Review of Resident #1's Orders, no date, reflected an order for Acyclovir Oral Capsule, Directions to Give 200 MG by mouth two times a day every Tue (Tuesday), Thu (Thursday), Sat (Saturday), Sun (Sunday) for eyes, ordered 08/31/2023, start 08/31/2023. Further review reflected a second order for Acyclovir Oral Capsule 200 MG (Acyclovir), Direction to Give 200 MG by mouth one time a day every Mon (Monday), Wed (Wednesday), Fri (Friday) for eyes AND Give 400 MG by mouth in the evening every Mon (Monday), Wed (Wednesday), Fri (Friday) for eyes., ordered 08/31/2023, start 09/01/2023. Further review of Resident #1's orders reflected an order for Trifluridine Ophthalmic Solution 1% (Trifluridine), Directions Instill 1 drop in right eye every 3 hours for Herpes Infection of the right eye 1 drop right eye 9x (9 times) a day, ordered 07/18/2023, start 07/19/2023. Review of Resident #1's MAR, dated 11/30/2023, reflected no documentation that Resident #1 received Acyclovir capsules on: 10/16/2023 Monday 18:00 (06:00 p.m.) 10/31/2023 Tuesday 20:00 (08:00 p.m.) 11/02/2023 Thursday 08:00 (8:00 a.m.), 20:00 (8:00 p.m.) 11/04/2023 Saturday 08:00 (8:00 a.m.), 20:00 (8:00 p.m.) 11/05/2023 Sunday 08:00 (8:00 a.m.), 20:00 (8:00 p.m.) Review of Resident #1's MAR, dated 11/30/2023, reflected no documentation that Resident #1 received Trifluridine on: 07/23/2023 Sunday 06:00 (06:00 a.m.) 07/27/2023 Thursday 06:00 (06:00 a.m.), 18:00 (06:00 p.m.) 08/02/2023 Wednesday 21:00 (09:00 p.m.) 08/03/2023 Thursday 00:00 (12:00 a.m.), 03:00 (03:00 a.m.) 08/05/2023 Saturday 06:00 (06:00 a.m.) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455554 If continuation sheet Page 12 of 20 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 455554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coral Rehabilitation and Nursing of McGregor 414 Johnson Dr MC Gregor, TX 76657 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 0760 08/09/2023 Wednesday 06:00 (06:00 a.m.) Level of Harm - Immediate jeopardy to resident health or safety 08/11/2023 Friday 06:00 (06:00 a.m.) Residents Affected - Some 08/18/2023 Friday 06:00 (06:00 a.m.) 08/12/2023 Saturday 18:00 (06:00 p.m.) 08/21/2023 Monday 06:00 (06:00 a.m.), 18:00 (06:00 p.m.) 08/27/2023 Sunday 06:00 (06:00 a.m.) 09/12/2023 Tuesday 21:00 (09:00 p.m.) 09/13/2023 Wednesday 00:00 (12:00 a.m.), 03:00 (03:00 a.m.), 06:00 (06:00 a.m.) 09/21/2023 Thursday 21:00 (09:00 p.m.) 09/24/2023 Sunday 06:00 (06:00 a.m.) 09/28/2023 Thursday 21:00 (09:00 p.m.) 09/29/2023 Friday 00:00 (12:00 a.m.), 03:00 (03:00 a.m.), 06:00 (06:00 a.m.) 10/16/2023 Monday 18:00 (06:00 p.m.) 10/22/2023 Sunday 15:00 (03:00 p.m.), 18:00 (06:00 p.m.) 10/24/2023 Tuesday 00:00 (12:00 a.m.), 03:00 (03:00 a.m.), 06:00 (06:00 a.m.) 10/25/2023 Wednesday 07:00 (07:00 a.m.) 10/26/2023 Thursday 07:00 (07:00 a.m.) 10/27/2023 Friday 07:00 (07:00 a.m.) 10/28/2023 Saturday 07:00 (07:00 a.m.) 10/29/2023 Sunday 07:00 (07:00 a.m.) 10/30/2023 Monday 07:00 (07:00 a.m.) 10/31/2023 Tuesday 07:00 (07:00 a.m.) 11/01/2023 Wednesday 07:00 (07:00 a.m.) 11/02/2023 Thursday 07:00 (07:00 a.m.) 11/03/2023 Friday 07:00 (07:00 a.m.) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455554 If continuation sheet Page 13 of 20 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 455554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coral Rehabilitation and Nursing of McGregor 414 Johnson Dr MC Gregor, TX 76657 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 0760 11/04/2023 Saturday 07:00 (07:00 a.m.) Level of Harm - Immediate jeopardy to resident health or safety 11/07/2023 Tuesday 07:00 (07:00 a.m.) Residents Affected - Some 11/09/2023 Thursday 07:00 (07:00 a.m.), 19:00 (07:00 p.m.) 11/08/2023 Wednesday 07:00 (07:00 a.m.) 11/10/2023 Friday 07:00 (07:00 a.m.) 11/11/2023 Saturday 07:00 (07:00 a.m.) 11/12/2023 Sunday 07:00 (07:00 a.m.) 11/13/2023 Monday 07:00 (07:00 a.m.) 11/14/2023 Tuesday 07:00 (07:00 a.m.) 11/16/2023 Thursday 07:00 (07:00 a.m.) 11/17/2023 Friday 07:00 (07:00 a.m.) 11/18/2023 Saturday 07:00 (07:00 a.m.) 11/19/2023 Sunday 07:00 (07:00 a.m.) 11/21/2023 Tuesday 07:00 (07:00 a.m.) 11/22/2023 Wednesday 07:00 (07:00 a.m.) 11/25/2023 Saturday 07:00 (07:00 a.m.) 11/27/2023 Monday 07:00 (07:00 a.m.) 11/28/2023 Tuesday 07:00 (07:00 a.m.) Review of Resident #1's Ophthalmologist records, dated 11/28/2023, reflected an exam performed revealed Ocular Adnexa (parts of the body that are connected to the surrounded eye) and Anterior Segment (eye cavity, front-most region of eye, includes the cornea, iris, and lens.) OD (oculus [NAME]-right eye), noted 2+Descemet Folds (manifestation of edema or inflammation in the cornea), Central Epithelial (body tissue) Defect with Rolled Edges, 1+Fluress Staining of Cornea. Procedure Prokera Slim (amniotic membrane that is thin and clear placed on the surface of the eye damaged tissue while inserted.) Interview on 11/30/2023 at 01:29 p.m., Resident #1's Ophthalmologist revealed concerns of Resident #1 receiving her medications for her eye infection. He further stated they had a typed version, of her schedule, of the Acyclovir, because there were concerns Resident #1 was not receiving it. He stated the ophthalmology provider started seeing Resident #1 in July for her right eye. He stated, her vision was somewhat decent, but from then on, her vision decreased. The Ophthalmologist stated that, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455554 If continuation sheet Page 14 of 20 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 455554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coral Rehabilitation and Nursing of McGregor 414 Johnson Dr MC Gregor, TX 76657 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Resident #1 went from being able to see large letters, to not being able to that all anymore, it (vision) has gotten worse. The Ophthalmologist further stated, It became apparent she (Resident #1) wasn't getting treatment, based on the exams, her (Resident #1) visual acuity has gotten worse. The Ophthalmologist stated that, its 100 percent important for all the orders to be completed, and I want to add that it is extremely important for her (Resident #1) to get the Acyclovir as prescribed and to be given consistently, despite her (Resident #1) history of diabetes, if she (Resident #1) had her consistent treatment, this would have been avoided, due to her (Resident #1) renal dialysis, she was getting less than the usual standard of care for the Acyclovir, therefore its more important to get it as when she gets dialyze the medication is removed from her system. The Ophthalmologist stated that, there was scarring in the cornea, in her (Resident #1) right eye, and we are suggesting corneal transplant. The Ophthalmologist explained, the last exam revealed the back layers, the Descemet folds, is a sign of edema (swelling) and/or infection. The rolled edges listed in her exam mean that the epithelial tissue is trying to grow back due to damage. Interview on 11/30/2023 at 02:46 p.m., Resident #1 stated when she got back from all her doctor's appointments, she gave the discharge orders and changes to her medications to nursing staff. Resident #1 stated there are times she does not have her eye medications for a week. Resident #1 stated that her right eye is the eye that she cannot see out of, and she stated that her vision got worse. Interview on 11/30/2023 at 03:26 p.m., ADON stated that when any resident returns from a specialist or outside provider visit, it was encouraged that residents are to give the discharge orders to the nurse, the nurse updates the orders in the resident's EHR, as prescribed, as instructed, as directed. Staff are to administer medications as instructed and document the process. ADON stated that the facility obtained its medications from an outside pharmacy provider, as ordered, and if medications are not available, staff are to contact the MD or NP and are to follow the procedure communicating with providers, checking the emergency medication kit. No other statement was made on Resident #1's missing medication administration. ADON could not determine why Resident #1 missed the undocumented medications orders. Interview on 12/01/2023 at 11:42 p.m., the MD stated she was only informed that (Resident #1) did not get her Trifluridine, MD is not aware of the other items related to the missing medication administrations. MD stated that when orders come in from outside providers, they are documented in the resident's EHR and followed. MD is not aware if Resident #1 gave her orders to the nurse, or if the ophthalmologist faxed the orders over, the MD stated there is no set protocol for this type of occasion as residents are encouraged to give their discharge orders from outside providers. MD could not determine why Resident #1 missed the undocumented medications orders. Interview on 12/01/2023 at 01:54 p.m., the NP stated she was not aware of the missing medications, and that outside specialist usually do not call us, typically nurses would communicate with her on all items that involve a resident, from changes of conditions to medications not being available. NP could not determine why Resident #1 missed the undocumented medications orders. Interview on 12/01/2023 at 2:10 p.m., MA A stated being familiar with Resident #1. MA A stated, if medications are not available, staff notify the resident's nurse, DON, and ADON, and medications can be reordered through the residents EHR, and that I can call pharmacy myself., MA A further stated, we attempt to keep medication filled and re-order medication five to seven days before the medications are expected to run out. MA A added that she was aware that Resident #1's Acyclovir was not available, although she cannot recall the exact time, it had been ordered, and as well as the Trifluridine. MA A stated the residents have these medications for a reason, their conditions, to treat the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455554 If continuation sheet Page 15 of 20 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 455554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coral Rehabilitation and Nursing of McGregor 414 Johnson Dr MC Gregor, TX 76657 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some residents so they may, get better. MA stated that when Resident #1's medications were not available, they were not here, she did not successfully administer the ordered medications to Resident #1. Interview on 12/01/2023 at 2:32 p.m., LVN A stated that, there are orders for medications, and when residents let us know the orders from outside providers, we placed them in, instructions, frequency, all details of the medications into the resident's EHR system. LVN A stated, to reorder medications, we use the EHR, orders are refilled five to seven days before medications are out to avoid missing medications, and if an event occurs in that there are no medications, we call the pharmacy, the NP or MD, and ask for alternatives. LVN A stated to check the overstock medications and the emergency medication kit. LVN A stated if the procedures for medication administration are not followed, it is detrimental to a resident's health and his or her plan of care. Record review of the facility's Medication: Reordering policy, effective 04/01/2017 and last reviewed 03/22/2023, reflected that, it is the policy of the facility to reorder medications when supply is running low (2 days prior), purpose is to ensure that all meds re available in sufficient quantity to fulfill MD orders. 5. Nurse responsibility, if medications is not received in a timely manner, recalls the pharmacy to obtain estimated delivery time. Notifies nursing supervisor, manager and DNS/ADNS (Director of nursing/Assistant director of nursing). 6. Nurse responsibility, if medication is not available for the specific medication notifies MD/NP to obtain hold order or substitute medication which may be available in emergency stock. Reorders medications form pharmacy through the EMR. Contacts pharmacy to ensure that reorder was received and confirmed estimated delivery time. 7. DNS/ADNS/NM/RNS responsibility, the nursing supervisor/NM or nursing administration will run a random report to ensure that all meds are administered as per MD order. Record review of the facility's Administering Medications policy, revised April 2019, reflected, Policy statement that Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 22. The individual administering the medication initials the resident's MAR in the appropriate line after giving each medication and before administering he next ones. The ADM was notified on 12/01/2023 at 04:17 p.m., that an IT situation was identified due to the above failures and the IT template was provided. The plan of Removal was accepted on 12/03/2023 at 09:36 a.m., and included: Immediate action: 12/02/2023 The resident affected by this deficiency (F755), was assessed and noted to be stable as of 12/02/2023. An audit of this resident's current list of medications was performed by the Administrator on 12/02/2023 and revealed that all current medications for this resident were delivered and are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455554 If continuation sheet Page 16 of 20 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 455554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coral Rehabilitation and Nursing of McGregor 414 Johnson Dr MC Gregor, TX 76657 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 0760 Level of Harm - Immediate jeopardy to resident health or safety available in the facility. The administration of the resident medications was assigned to the charge nurse on the hall. The am and pm doses were adjusted so they would align with her blood sugar checks. An audit of this resident's medication administration record (MAR), conducted on 12/02/2023 by the administrator, revealed that all current ordered medications are being administered according to the instructions on the physician orders. Residents Affected - Some Training of staff and audits of all medication were initiated by the Administrator and ADON on 12/02/2023 Identification of others: All residents have the potential to be impacted by this deficient practice. The Administrator conducted an audit of the medication list of all residents within the facility on 12/02/2023 and found that all medications are available within the facility. The Administrator conducted a medication administration record (MAR) audit for all residents in the facility on 12/02/2023 to ensure accuracy of medication administration and found that all ordered medications were being administered to all residents accurately according to physician's orders. No other resident was found to be affected. The Administrator has started an education for all Nursing staff on Medication Administration with a focus on ensuring accuracy, expected completion date is 12/2/23. All staff that administer medications and receive orders have been educated as of 12/02/2023. The Regional Nurse Consultant provided an education on conducting medication list audits to the administrator, Director of Nursing, and ADON on 12/02/2023. The Regional Nurse Consultant provided and education on conducting MAR audits to the administrator and Director of Nursing on 12/02/2023. The Regional Nurse Consultant has updated the facility's procedure for communicating with outside Physicians and Clinics, which includes contacting physicians and confirming orders, on 12/02/2023. The Regional Nurse Consultant has updated the facility's policy on communication, contacting Physicians and confirming orders, on 12/02/2023 to reflect these new changes. The Regional Nurse Consultant has provided education to the administrator, Director of Nursing, and ADON on 12/02/2023, regarding these changes and policy updates. The Regional Nurse Consultant has educated the Administrator, DON and ADON on conducting audits of the facility's communication procedure, including contacting physicians and confirming orders, on 12/02/2023. The administrator has created and audit to monitor compliance to the facility's communication procedure for contacting Physicians and confirming orders. Audits will be conducted by the ADON daily for two weeks, weekly for 2 weeks and monthly for two months. Any negative findings will be reported to the administrator for immediate correction. The Administrator and ADON has started an education for all staff on communicating, contacting physicians and verifying orders, expected completion date is 12/02/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455554 If continuation sheet Page 17 of 20 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 455554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coral Rehabilitation and Nursing of McGregor 414 Johnson Dr MC Gregor, TX 76657 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some The administrator has created a MAR audit to monitor for accuracy of medication administration on 12/02/2023. ADON will conduct MAR audits to ensure the accuracy of medication administration, daily for two weeks, weekly for two weeks and monthly for two months. Any negative findings will be taken to the administrator for immediate correction. The DON, or ADON will continue to audit the medication administration in the building on Mondays and Thursday as part of the facility ongoing process to ensure accuracy of medication administration. The results of the new audit process will be reported to the QAPI team. The Medical Director was notified of the deficiency (F755) on 12/01/2023 and an Ad-Hoc QAPI meeting was held on 12/02/2023 to discuss the findings. All findings will be reported to the QAPI team for QAPI. Expected compliance date is 12/02/2023. The Survey Team monitored the Plan of Removal on 12/03/2023 to 12/04/2023: Interview on 12/03/2023 from 04:15 p.m. to 04:17 p.m., CNA A, CNA B and CNA C confirmed they have taken in-services on education administration or missing medications to notify ADM, DON, ADON immediately, stating that if they heard a resident had a medication issue to tell the MA, DON, ADON or the ADM. Interview on 12/03/2023 from 04:20 p.m. to 04:35 p.m., MA A and MA B confirmed they have taken the in-services on medication pass education and education administration/missing medications to notify ADM, DON, ADON immediately. Interview on 12/04/2023 at 10:45 a.m., MA C confirmed in-services on medication pass education and education on administration/missing medications to notify ADM, DON, ADON immediately. MA C stated, when medications are reordered, and the medications are not at the facility in a timely manner, we call the pharmacy, get the nurse, the ADM, DON and ADON involved. MA C stated, we look in the residents' MAR to see what medications are missing, and fax orders to the pharmacy, or order medications through the resident's EHR, and call the pharmacy to check status and estimated time of delivery. MA C confirmed education on checking the facility's overflow medications if missing medications are available. MA C is aware that MD and NP are to be notified by nurses to check for alternative medications. Interview on 12/04/2023 from 10:52 a.m. to 11:09 a.m., the DON and ADON confirmed in-services, education and process of medication administration with a focus on ensuring accuracy, conducting medication list audits and sending audits to ADM, communicating with outside physicians and clinics, contacting physicians and confirming orders, audit to monitor compliance of the facility's communication procedure for contacting physicians and confirming orders. DON and ADON confirmed audits are conducted daily for two weeks, weekly for 2 weeks, and monthly for two months. DON and ADON confirmed that negative are to be reported to the ADM for immediate correction. DON and ADON confirmed process to conduct MAR audits to ensure the accuracy of medication administration daily for two weeks, weekly for two weeks, and monthly for two months. DON and ADON confirmed any negative findings are to be taken to the Administrator for immediate correction. DON and ADON stated that the MD was notified of deficiency and Ad-Hoc QAPI meeting was held on 12/02/2023 to discuss findings and provide immediate interventions. DON and ADON stated that the facility has a new for called the missing medication form. The form documents the name of the resident, missing medication, name of nurse notified, time (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455554 If continuation sheet Page 18 of 20 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 455554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coral Rehabilitation and Nursing of McGregor 414 Johnson Dr MC Gregor, TX 76657 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some pharmacy called, pharmacy staff name, ETA of medication delivery, and was medication delivered as stated in the ETA of medication delivery. Interview on 12/04/2023 at 11:12 a.m., TS A confirmed an updated process during specialist or outside provider visits, TS A would have outside providers complete a form called a visit summary. The summary is given to the DON, ADON, and charge nurse. Staff stated this form would be used to assure accurate discharge orders are given to the nurse. Interview on 12/04/2023 at 11:38 a.m., MA A stated she took the in-services on medication pass education and education administration/missing medications. MA A stated, If I hear a resident has a medication issue to tell the DON ADON or the ADM. and it is important to follow up on the new process, and the risks of not following the process could negatively affect residents' health and well-being. Interview on 12/04/2023 on 01:09 p.m., the MD stated that an Ad-Hoc QAPI meeting was attended on 12/02/2023 to discuss non-compliance IT, and plan of intervention. MD stated that there are new processes as well to electronically fax all new orders to her to make sure they are in residents EHR. Interview on 12/04/2023 on 01:11 p.m., the NP stated that all new medication orders will be placed in her care folder to be reviewed and to assure communication is accurate, check all medication, and ensure all new medications are in the residents' EHR. Interview on 12/04/2023 on 01:32 p.m., the ADM stated and confirmed in-services, education, and process of Medication Administration with a focus on ensuring accuracy, conducting medication list audits that are to be sent to her, communicating with outside Physicians and Clinics, which includes contacting physicians and confirming orders, audit to monitor compliance to the facility's communication procedure for contacting Physicians and confirming orders. ADM stated audits will be conducted daily for two weeks, weekly for 2 weeks, and monthly for two months. Any negative findings will be reported to her for immediate correction. ADM stated DON and ADON will conduct MAR audits to ensure the accuracy of medication administration, daily for two weeks, weekly for two weeks, and monthly for two months. Any negative findings will be taken to her for immediate correction. The ADM stated that the MD was notified of the deficiency and an Ad-Hoc QAPI meeting was held on 12/02/2023 to discuss the findings and provide immediate interventions. ADM stated that the facility has a new form, missing medication form, that is used if the medication is unable to be obtained to notify nurse management. The ADM stated the next QAPI meeting is scheduled on 12/18/2023, audits will be discussed to assure accuracy. ADM stated that MA A has been documented of having a corrective action placed in her employee file. Record review on 12/04/2023, reflected medication administration record (MAR) audit for all residents completed. Record review on 12/04/2023, reflected medication administration record (MAR) audit for all residents with no significant findings. Record review on 12/04/2023, reflected orders in Resident #1 EHR, Acyclovir Oral Capsule 200 MG and Trifluridine Drops 9 x daily. Record review on 12/04/2023, reflected medication administration for scheduled Acyclovir and Trifluridine, no medications missed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455554 If continuation sheet Page 19 of 20 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 455554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coral Rehabilitation and Nursing of McGregor 414 Johnson Dr MC Gregor, TX 76657 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review on 12/04/2023, reflected in-services and education on Medication Administration with a focus on ensuring accuracy, conducting medication list audits to the administrator, education for all staff on communicating, contacting physicians, and verifying orders, and Ad-Hoc QAPI conduced on 12/02/2023. Record review on Communication with Consultants policy, last review 05/28/2023, it is policy of facility to maintain effective communication between members of the care team, including but not limited to MDs, Nurses, Consultants, outside clinics and health care facilities (hospitals, nursing homes, etc.). General information, the License nurse will ensure that a copy of the facility's consultation form, is sent with each resident going for an outside appointment. Will prefill the consult form with the resident's name, DOB and reason for visit, upon return the License nurse will receive and review the returning consultation form, which would not have been completed by the consulting physician, with findings and recommendations/orders where necessary. If the form is not returned, or returned incomplete, the license nurse will reach out to clinic, hospital, or local MD office to obtain recommendations for the target resident, following their appointment, will repeat the information once received to ensure accuracy and completeness, will request a fax copy of this information if possible. Record review on 12/04/2023, reflected a Personnel Action form for MA A, dated 12/02/2023, : failure to obey orders, Remarks: 1. Medication not administered in a timely fashion. 2. OTC not administered. 3. Nurse not notified the medications not available. It is the expectation that all medications will be administer as ordered and within the timeline parameters. Issues with meds (medications) will be reported immediately. Due to severity of actions this is a level 3., signed and dated by ADM on 12/02/2023. The ADM was notified on 12/04/2023 at 2:19 p.m. that the Immediate Jeopardy was lowered. While the IJ was removed on 12/04/2023, the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not Immediate Jeopardy because of the facility's need to evaluate the effectiveness of the corrective systems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455554 If continuation sheet Page 20 of 20