Health inspection·January 6, 2023

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. Page 1 of 5 675312 675312 01/06/2023 Palma Real 1220 Loop 459 Mathis, TX 78368

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. 675312 Page 2 of 5 675312 01/06/2023 Palma Real 1220 Loop 459 Mathis, TX 78368

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 675312 Page 3 of 5 675312 01/06/2023 Palma Real 1220 Loop 459 Mathis, TX 78368

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 675312 Page 4 of 5 675312 01/06/2023 Palma Real 1220 Loop 459 Mathis, TX 78368

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. 675312 Page 5 of 5