Health inspection·November 13, 2023

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, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for one of the residents (R# 1) of five that were reviewed for infection control and transmission-based precautions policies and practices, in that: Residents Affected - Few a.CNA A did not cleanse the catheter tubing while providing catheter care. These failures could place residents at risk for infection through cross contamination of pathogens. The findings included: Record review of R#1's Face Sheet dated 11/13/2023, admitted [DATE], documented a [AGE] year-old male with the following diagnoses of: Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dysphagia (swallowing difficulties), chronic ischemic heart disease, benign prostatic hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty). Record review of R #1's MDS dated [DATE], revealed R#1 had a 02/15 BIMS score documenting a severe cognitive impairment. R#1 was coded to have an indwelling catheter. R#1 also required extensive assistance of staff to assist in activities of daily living. Record review of R #1's Comprehensive Care Plan date initiated 10/19/2023 revealed, R#1 has a foley catheter and was at risk for increased UTI's. due to urinary retention. Interventions: change the foley catheter, tubing, and bag per order. Ensure leg strap or other method to secure catheter is in place unless contraindicated. Monitor urine for odor, color, sediments and amount of urine, and report abnormalities to MD. Encourage PO and fluid intake within dietary limits. Keep tubing/bag below the bladder, do not kink tubing. Perform catheter care per order. Record review of R#1's Physician Order dated 03/09/2023 revealed: Indwelling catheter care every shift with soap and water or may use wipes as appropriate/ desired by patient. During an observation on 11/13/2023 at 12:53PM, while providing catheter care on R#1, CNA A cleaned the penile area but did not cleanse from the meatus (opening) outward for at least 4 inches of catheter tubing. (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: 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 11/13/2023 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)