Health inspection·December 11, 2024

F 0638 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some allergen is unknown), Anxiety Disorder, Unspecified ( diagnosis given to someone who experiences anxiety or phobias that are significant but don't meet the criteria for a specific anxiety disorder), Gastro-Esophageal Reflux Disease without Esophagitis (a type of GERD that doesn't cause inflammation of the esophagus). Review of Resident #55's last completed MDS assessment dated [DATE] reflected a BIMS score of: 03 which indicated severe cognitive impairment. Further review of Resident #55's MDS tracking record reflected the last completed MDS was completed on 06-21-2024. The next MDS listed was a quarterly dated [DATE] and [DATE] that was in progress as of [DATE]. Review of Resident #56's electronic face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses to include: Dementia in other diseases Classified elsewhere, Mild, with Mood Disturbance (is a chronic condition that causes a progressive loss of cognitive functioning, including memory, thinking, and reasoning skills), Restless and Agitation (restless moving, shouting, twitching or jerking of the body), Essential Primary Hypertension (pressure of the blood in your blood vessels is consistently too high), Unspecified Psychosis not due to a Substance or known Psychological Condition (psychotic symptoms that are not caused by a substance or known physiological condition), Bipolar Disorder, Unspecified (a mood disorder diagnosis given to people who have symptoms similar to bipolar disorder but don't meet the criteria for a specific type of bipolar disorder), Unspecified Mood (Affective) Disorder (diagnostic category for mood disorders that don't meet the full criteria for a specific diagnosis), Type 2 Diabetes Mellitus without Complications (a chronic condition that occurs when the body doesn't produce enough insulin or doesn't use insulin properly, resulting in high blood sugar levels). Review of Resident #56's last completed MDS assessment dated [DATE] reflected a BIMS score of: 00 which indicated severe cognitive impairment. Further review of Resident #56's MDS tracking record reflected the last completed MDS was completed on 06-11-2024. The next MDS listed was a quarterly dated [DATE] that was in progress as of [DATE]. Review of Resident #58's electronic face sheet reflected a [AGE] year-old male admitted on [DATE] with diagnoses to include: Displaced Fracture of base of neck or right Femur, Sequela (a broken bone at the top of the right thigh bone (femur), near the hip joint, where the broken pieces of bone are significantly moved out of their normal alignment, causing a displacement), Unilateral Primary Osteoarthritis, right knee (a degenerative joint disease that affects one side of the body, usually in the knees, hips, or hands), Hypertension (pressure of the blood in your blood vessels is consistently too high), Age-Related Cognitive decline (a gradual or sudden decline in mental capabilities, such as memory, thinking, and concentration), Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety (is a chronic condition that causes a progressive loss of cognitive functioning, including memory, thinking, and reasoning skills), Depression, Unspecified (diagnostic term used when someone has symptoms of a depressive disorder, but the symptoms don't meet the criteria for a specific depressive disorder. Review of Resident #58's last completed MDS assessment dated [DATE] reflected a BIMS score of: 09 which indicated moderate impairment. Further review of Resident #58's MDS tracking record reflected the last completed MDS was completed on 03-20-2024. The next MDS listed was a quarterly dated [DATE] and [DATE] that was in progress as of [DATE]. During an interview on [DATE] at 2:20 PM, the ADMN stated MDS assessments were to be completed annually and quarterly. He stated his expectation was for MDS assessments to be completed and submitted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455554 If continuation sheet Page 2 of 5 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 12/11/2024 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)

F 0638 Level of Harm - Minimal harm or potential for actual harm within the required time frame. He stated the problem was they do not have an MDS coordinator or a social worker, but they were in the process of trying to find and hire someone. He stated if the MDS was not completed timely, they would have been out of compliance with the state's regulations. He stated he didn't think it would affect the care of the residents if it was not signed and the staff knows what was needed to do their job. Residents Affected - Some During an interview on [DATE] at 2:10 PM, the DON stated she was not aware that MDS assessments were not being completed and submitted within a timely manner. She stated the MDS coordinator quit 2 weeks ago. She stated there was a cooperate MDS person, but they needed an in-house MDS coordinator. She stated if the MDS's were not completed timely, the staff would not have accurate information to care for the residents. She stated she was trying to assist and get the MDS' caught up. Review of facility policy titled, Resident Assessment Instrument, revised [DATE], reflected in part: .Policy Interpretation and Implementation: 1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct a timely resident assessments and reviews according to the following schedule: a. Within fourteen days of resident's admission to the facility; b. Where there has been a significant change in the resident's condition; c. At least quarterly; and d. Once every twelve months . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455554 If continuation sheet Page 3 of 5 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 12/11/2024 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)

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. Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: - Food items were not labeled and/or dated. Some food items that were labeled were out date. These failures could place all residents who received meals from the main kitchen at risk for food borne illness. Findings include: Observation on 12/09/2024 at 7:15 am of the pantry reflected the following: The dried pantry had food that was not dated and some food that was out of date, Baking soda that had an expiration date of was dated 8-23-24. Observation on 12/9/2024 at 7:25 am of the walk-in cooler reflected the following. Soup that was dated use by 12-2-2024. Sauce in a squeeze bottle that was not dated. Jelly that was dated use by 11-26-2024. Unknown food with no date. Cheese that was dated use by 12-4-2024. Potato soup that was dated use by 12-5-2024 During an interview on 12/09/24 at 7:45 am the KM was made aware of the items that were out of date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455554 If continuation sheet Page 4 of 5 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 12/11/2024 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)

F 0812 and other items not being labeled. The KM said that he was going to get that corrected. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/11/24 at 10:40 am - the KM stated that they were supposed to date all food in the kitchen. - The KM stated that they checked for out-of-date food daily. The KM stated that if they used outdated food then residents could get a food born illness if out of date food was served. KM said that he was responsible for overseeing the dates of the food in the kitchen. The KM stated that he had a food handlers' certificate. Residents Affected - Some During an interview with the KA on 12/11/24 at 10:50 am, KA stated that they put dates on food as they go. The KA stated that they checked for out-of-date food daily. The KA stated that if out of date food was served, then residents could get sick. The KA stated that he had a food handlers' certificate. During an interview on - 12/11/24 at 10:55 am with the KC said that they date food as they go. The KC stated that they checked for out-of-date food in the kitchen daily. The KC stated that if out of date food was served then residents could get sick. The KC stated that he had a food handlers' certificate. Observation on 12/11/2024 at 10:20 am of the pantry and walk in cooler revealed the out-of-date items had been removed and items that were not labeled were labeled. Record review of the undated Dietary Service Policy - Department Operations Food Receiving and Storage, read in part. Policy Statement: Foods shall be received and stored in a manner that complies with safe food labeling practices. Policy Interpretation and Implementation 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated ('use by date). 9. Refrigerated foods will be stored in a way that promotes adequate air circulation around food storage containers. Refrigerators/walk-ins will not be overcrowded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455554 If continuation sheet Page 5 of 5