Health inspection·August 24, 2024

F 0880 Provide and implement an infection prevention and control program. 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 maintain an Infection Control Program designed to help prevent the development and transmission of disease for 2 (Residents #1 and Resident #2) of 8 residents reviewed for infection control during medication pass. Residents Affected - Few LVN A failed to remove her gloves and wash her hands before putting on a new set of gloves and after touching the peg tube of Resident #1, and then touching the gtube of Resident #2. These failures placed residents at an increased risk of exposure to infections, decreased quality of life or hospitalizations. Findings include: 1. Review of Resident #1's face sheet, dated 08/24/24, reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] diagnosed with supraventricular tachycardia (erratic heartbeat), anoxic brain damage (occurs when the brain is deprived of oxygen), and personal history of traumatic brain injury. Review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS was not conducted because the resident was rarely/never understood). Section K Swallowing/Nutritional Status revealed feeding tube. Review of Resident #1's care plan revealed a focus of nothing by mouth due to dysphagia (difficulty swallowing). He was a high nutrition/hydration risk as dependent on PEG to meet all nutrition needs. 2. Review of Resident #2's face sheet, dated 08/24/24, reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] diagnosed with reduction deformities of brain and cerebral palsy (damage to or abnormalities inside the developing brain that disrupt the brain's ability to control movement). Review of Resident #2's quarterly MDS assessment dated [DATE] reflected a BIMS was not conducted because the resident was rarely/never understood). Section K - Swallowing/Nutritional Status revealed feeding tube. Review of Resident #2's care plan revealed a focus of Resident #2 has potential for nutritional/hydration/aspiration risk due to G-TUBE in place for nutritional and hydration due to diagnosis of cerebral palsy and dysphagia. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 455554 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 08/24/2024 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)