Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record reviews the facility failed to ensure a medication error rate below 5%
for 1 of 2 Residents (Resident #26) reviewed for medication administration errors, in that:
Residents Affected - Some
MA A administered 26 medications of which 8 were administered to Resident #26 50 minutes after they
were scheduled, which resulted in a 30% medication error rate.
This failure could place residents at risk for not receiving therapeutic effects of their medications and
possible adverse reactions.
The findings included:
A record review of Resident #26's face sheet, dated 1/5/2022, revealed an admission date of 5/8/2019 with
diagnoses which included pain, hypertension [high blood pressure], neuralgia [a sharp, shocking pain that
follows the path of a nerve], pain, and hypokalemia [a low level of potassium in the blood. Potassium helps
control how muscles, the heart, and the digestive system work].
A record review of Resident #26's quarterly MDS, dated [DATE], revealed Resident #26 was an [AGE]
year-old female assessed with a mildly impaired cognition.
A record review of Resident #26's physician's orders revealed Resident #26 was to receive the following
medications daily at 7:00 AM: docusate 100mg two times daily for constipation; furosemide 40mg two times
daily for edema; gabapentin 100mg three times daily, for neuralgia; hydralazine 25mg two times a day for
high blood pressure; hydrocodone 10mg, acetaminophen 325mg three times a day, for pain; labetalol
200mg two times daily, for high blood pressure; lisinopril 10mg two times daily, for high blood pressure; and
potassium chloride 10 mEq two times a day for low potassium.
During an observation on 1/5/2023 at 8:50 AM revealed MA A administered medications to Resident #26 at
8:50 AM which were scheduled for 7:00 AM. The medications were as follows: docusate 100mg two times
daily for constipation; furosemide 40mg two times daily for edema; gabapentin 100mg three times daily, for
neuralgia; hydralazine 25mg two times a day for high blood pressure; hydrocodone 10mg, acetaminophen
325mg three times a day, for pain; labetalol 200mg two times daily, for high blood pressure; lisinopril 10mg
two times daily, for high blood pressure; and potassium chloride 10 mEq two times a day for low potassium.
During an interview on 1/5/2023 at 8:52 AM MA A stated she administered Resident #26's 7:00 AM
medications at 8:50 AM, late, due to her duties to administer medications to the facility's entire census of 62
residents. MA A stated she began her duties a 6:00 AM and was scheduled for a 16-hour day.
(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 5
Event ID:
675312
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
675312
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palma Real
1220 Loop 459
Mathis, TX 78368
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 0759
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
MA A stated she had been employed as the MA for longer than a year and was late due to other duties
besides medication administration. MA A stated, You saw me in the dining room assisting residents with
their meals. MA A stated Resident #26 was not the last resident who needed medications. MA A stated she
still had many more residents to administer medications to. MA A stated she had not alerted anyone to her
late medication administration. MA A stated her supervisor was the ADON. MA A stated it was her
responsibility to administer medications on time meaning 1 hour prior and/or 1 hour after the scheduled
time; 7 AM meds no later than 8 AM. MA A stated there may be risks if residents did not receive
medications on time.
During an interview on 1/5/2022 at 2:20 PM the ADON stated she was MA A's supervisor, and she was not
given a report about MA A's late medication pass. The ADON stated MA A was responsible for
administering medications for Residents at the time the medications were scheduled and if she could not,
MA A should have reported the failure to the ADON. The ADON stated if she had learned of the late
medication administration, she could have intervened to ensure residents received their medications as
scheduled.
A record review of the facility's medication error rate policy was not possible due to the request for a policy,
made of the ADON and the Administrator on 1/5/2022 at 2:20 resulted in a policy titled medications which
did not address the medication error rate.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675312
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
675312
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palma Real
1220 Loop 459
Mathis, TX 78368
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 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
observations, interviews, and record reviews the facility failed to establish an infection prevention and
control program (IPCP) that must include, at a minimum, a system for preventing, identifying, reporting,
investigating, and controlling infections and communicable diseases for all residents, staff, volunteers,
visitors, and other individuals based upon the facility assessment conducted according to and following
accepted national standards, for 1 of 1 facility's reviewed for an established process to make everyone
entering the facility aware of recommended actions to prevent transmission to others if they have any of the
following three criteria:
Residents Affected - Some
1) a positive viral test for SARS-CoV-2
2) symptoms of COVID-19, [Possible symptoms include Fever or chills, Cough, Shortness of breath or
difficulty breathing, Fatigue, Muscle or body aches, Headache, New loss of taste or smell, Sore throat,
Congestion or runny nose, Nausea or vomiting, Diarrhea] or
3) close contact with someone with SARS-CoV-2 infection (for patients and visitors) or a higher-risk
exposure (for healthcare personnel (HCP)), in that:
The facility did not have an established process to make everyone entering the facility aware of
recommended actions to prevent transmission to others if they have any of the following three criteria:
1) a positive viral test for SARS-CoV-2
2) symptoms of COVID-19,
3) close contact with someone with SARS-CoV-2 infection (for patients and visitors) or a higher-risk
exposure (for healthcare personnel (HCP))
This failure could place residents at risk for contracting the SARS-CoV-2 virus during a COVID-19
pandemic.
The findings include:
During an observation and record review on 01/03/2023 at 08:10 AM revealed the facility's front entrance
door was decorated with a holiday [NAME] which partially obstructed an 8x11 CDC poster titled, What
healthcare personnel should know about caring for patients with confirmed or possible coronavirus disease
2019 (COVID-19). The poster did not reveal recommended actions, for visitors, to prevent transmission to
others if they have any of the following three criteria:
1) a positive viral test for SARS-CoV-2
2) symptoms of COVID-19, [Possible symptoms include Fever or chills, Cough, Shortness of breath or
difficulty breathing, Fatigue, Muscle or body aches, Headache, New loss of taste or smell, Sore throat,
Congestion or runny nose, Nausea or vomiting, Diarrhea] or
3) close contact with someone with SARS-CoV-2 infection (for patients and visitors) or a
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675312
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
675312
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palma Real
1220 Loop 459
Mathis, TX 78368
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 0880
higher-risk exposure (for healthcare personnel (HCP)).
Level of Harm - Minimal harm
or potential for actual harm
During an observation on 01/03/2022 at 08:14 AM revealed 2 surveyors visiting the facility self-signed in via
an automated electronic visitor's log and were not provided any recommended actions to prevent
COVID-19 transmission to others.
Residents Affected - Some
A record review of Resident #38's face sheet revealed an admission date of 9/29/2022, with diagnoses
which included influenza due to unspecified influenza virus [flu virus].
A record review of Resident #38's quarterly MDS, dated [DATE], revealed Resident #38 was an [AGE]
year-old medically complex female with mild impaired cognition and was hard of hearing.
A record review of Resident #38's care plan, dated 01/05/2023, revealed, COVID-19 risk-resident is at risk
for psychosocial well-being concern related to medically imposed restrictions related to COVID-19
precautions . educate staff the Resident's family and visitors of COVID-19 signs and symptoms and
precautions.
During an observation and interview on 01/03/2023 at 10:50 AM revealed Resident #38 was in her room
with a visitor/family member. Resident #38 and her visitor wore surgical masks. Resident #38's visitor stated
she used the self-sign automated electronic visitor's log and was not provided any recommended actions if
she was COVID-19 positive, exposed to COVID-19, and/or if she had signs and symptoms of COVID-19
prior to visiting with Resident #38. Resident #38's visitor / family member stated, I just signed in with my
name and [Resident #38's] name. Resident #38's visitor/family stated she had not been called attention to
any facility posters.
A record review of Resident #264's face sheet, dated 01/04/2022, revealed an admission date of
12/26/2022 with diagnoses which included COVID-19.
A record review of Resident #264's admission MDS, dated [DATE], revealed Resident #264 was an [AGE]
year-old male with severe mental cognition impairment diagnosed with COVID-19.
A record review of Resident #264's care plan, dated 01/04/2022, revealed, COVID-19 risk-resident is at risk
for psychosocial wellbeing concern related to medically imposed restrictions related to COVID-19
precautions . educate staff, Resident, family and visitors of COVID-19 signs and symptoms and
precautions.
During an observation and interview on 01/03/2023 at 5:15 PM revealed Resident #264 in his room with his
visitor/ family. Further observation revealed neither he nor his visitor/ family member wore a face mask.
Resident #264's visitor stated she used the self-sign automated electronic visitor's log and was not
provided any recommendations actions if she was COVID-19 positive, exposed to COVID-19, and/or if she
had signs and symptoms of COVID-19 prior to visiting with Resident #264, my [Resident #264] just got here
. he is under isolation . no one told me if I need to wear a face mask Resident #264's visitor/family stated
she had not called attention to any facility posters.
Observation on 01/04/2023 at 10:20 AM revealed 4 visitors arrived at the facility's entrance with one of the
visitors stating, we are here to visit Resident #264. Observed visitors were assisted by the ADON with
utilizing the automated electronic visitors' log. Observation revealed visitors were not provided any
recommended actions to prevent COVID-19 transmission to others
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675312
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
675312
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palma Real
1220 Loop 459
Mathis, TX 78368
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 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
During an observation and interview on 01/04/2023 at 10:27 AM the Medical Records Technician (MRT)
stated she was assigned to assist visitors with utilizing the automated electronic visitors' log. The MRT
stated someone was not always posted to assist visitors and today at this time it was her turn to assist
visitors with the automated electronic visitors' log. MRT demonstrated the automated electronic visitors' log
by assisting this surveyor to sign in as if this surveyor was visiting the facility. Throughout the demonstration
this surveyor was never provided any recommended actions to prevent COVID-19 transmission to others.
During an interview on 01/05/2023 at 4:00 PM with the Administrator, the DON, and the ADON Infection
Preventionist, the ADON Infection Preventionist stated the facility followed the CDC guidelines for
COVID-19 infection prevention and control. The Administrator stated the facility's corporation leadership
removed the COVID-19 screening questions from the automated electronic log in system due to relaxed
requirements removing COVID-19 screening. The DON concurred. The Administrator stated the facility
established a process to make everyone entering the facility aware of recommended actions to prevent
COVID-19 transmission to others by displaying an 8x11 CDC poster titled, What healthcare personnel
should know about caring for patients with confirmed or possible coronavirus disease 2019 (COVID-19) on
the facility's front door. The Administrator then demonstrated the signage, which was partially obstructed by
a holiday [NAME], to which the Administrator removed the [NAME]. The Administrator did not state how the
poster provided recommended actions, for visitors, to prevent transmission to others.
A record review of the facility's policy titled Coronavirus - COVID-19 Protocols, dated 10/04/2022, revealed,
Coronavirus (COVID-19) poses a serious threat to adults, 65 and over, especially those greater than [AGE]
years old and for those patients with underlying health conditions. Processes have been established in
order to decrease risk of exposure, transmission and to determine appropriate tasks . all individuals are
encouraged to stay home if respiratory symptoms and or COVID-19 symptoms are present . educate and
keep patients, patient responsible parties, employees and vendors, updated on COVID-19 findings as new
information becomes available from the local/state/federal government . Visitors: no screening required .
facility should provide guidance via posted signs at the entrances for recommended actions for visitors who
are COVID positive, have symptoms of COVID-19, or have had a close contact exposure. visitors with
confirmed COVID infection or symptoms should defer non urgent visits until they meet the CDC criteria for
healthcare settings to end isolation. visitors who have had close contact with someone with COVID-19
should defer non urgent visits until 10 days after their close contact if they meet criteria described in CDC
guidance . the facility will follow CDC, CMS, state, and local health authority guidance at all times.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675312
If continuation sheet
Page 5 of 5
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the January 6, 2023 survey of PALMA REAL?
This was a inspection survey of PALMA REAL on January 6, 2023. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PALMA REAL on January 6, 2023?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure medication error rates are not 5 percent or greater."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.