Health inspection·February 23, 2024

F 0656 Status. STATUS: Active (current). Level of Harm - Minimal harm or potential for actual harm Record review of Resident #4's care plan dated 02/24/23 indicated a Code status of DNR with a goal of Code Status will be maintained over the next 90 days or until resident or family desires a change. The interventions included inform staff of FULL CODE STATUS. STATUS: Active (current). Residents Affected - Few 2)Record review of the admission record dated 11/08/20 for Resident #36 revealed Resident #36 had a re-entry date of 10/22/23 and was a [AGE] year-old female. Resident #36's diagnoses included a stroke with right sided weakness, diabetes, high blood pressure, depression, insomnia, dementia, nutritional deficiency, schizoaffective disorder, anxiety, reflux, and was a smoker. Record review of Resident # 36's MDS assessment dated [DATE] indicated Resident #36 was cognitively intact with a BIMS of 15, required set-up for eating and substantial to partial assistance for all other ADL's. The MDS dated [DATE] indicated Resident #36 required a mechanically altered diet. Record review of Resident #36's physician orders revealed a diet for Regular Diet dated 12/23/23 and 03/01/23. The physician orders did not include a regular ground diet, LCS (low concentrated sweets) NSOT (no salt on tray) until 02/20/24. Record review of Resident #36's care plans dated 02/20/23, indicated no care plan for a therapeutic diet. There was an entry dated 08/30/23 for a protein supplement 30ml once daily x 30 days. STATUS: Active (current). There was an entry that indicated Resident #36 had no natural teeth or tooth fragments with an intervention to provide a mechanically altered diet (grind meat) dated 08/30/23 STATUS: Active (current). Record review of Resident #36's Nursing admission assessment dated [DATE] indicated under Nutrition: Own Teeth? With the answer yes, Specialized Diet required? Answer No, Check all that apply-difficulty chewing. Interview on 02/21/24 at 9:03 am with Resident #36 stated she was getting a regular diet and sometimes they chopped it up, but they were not supposed to. Resident #36 stated it was ok with her (that they chopped it) because she has had a dominant side stroke and eating made her tired. Resident #36 stated she wore a bridge in her mouth. Interview on 02/23/24 at 10:22 am with the ADM stated the care plans were a team effort-everyone does their part. they recently did a validation review with the corporation around the end of December to make sure the care plans were complete and accurate. The ADM stated they did education and action plans (PIP=performance improvement plans) for missing a diet, specialty wheelchairs, fall preventions, and others-she stated she could not remember nor could pull up the link from the validation review on her computer. The ADM stated each department was ultimately responsible for care plans and review the care plans weekly. The ADM stated she and the DON were ultimately responsible for the accuracy and timeliness of all care plans. The ADM stated there was always room for improvement and they discussed care plans in their monthly QAPI meetings and care plans were always important. Review of Care Plans, Comprehensive Person-Centered facility Policy revised 03/2022 stated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675312 If continuation sheet Page 2 of 9 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 02/23/2024 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 0656 Policy Interpretation and Implementation: Level of Harm - Minimal harm or potential for actual harm 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Residents Affected - Few 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. 12. The IDT reviews and updates the care plan: a. when there has been a significant change in the resident's condition. b. when the desired outcome is not met. c. when the resident has been re-admitted to the facility from a hospital stay. d. at least quarterly, in conjunction with the required quarterly MDS assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675312 If continuation sheet Page 3 of 9 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 02/23/2024 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 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, interview, 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 sanitation in that: A. Food temperature was not taken prior to serving meal. B. Hot foods were served at an unsafe temperature level. These failures could place residents who eat foods prepared in the kitchen at risk of cross contamination and food-borne illnesses. Findings include: During observation and interview on 02/22/24 at 8:03 AM the Kitchen Aide was plating food. The Kitchen Aide stated no, temperatures had been taken. Further observation of the temperature log revealed , no temperatures were logged in for AM of 2/22/24. The Kitchen Aide took the temperatures of food. Temperatures revealed scrambled eggs temperature of 165 degrees, puree eggs temperature was 167 degrees. The Kitchen Aide stated she was very busy and rushed and that she did not take time to take temperatures. The Kitchen Aide stated that not checking if food was at the correct temperature required could cause food borne illness. Upon the test tray observation on 02/22/24 @ 8:13am, the oatmeal had a temperature of 177 degrees. This temperature was taken by the investigator with the Dietary Manager present. The Dietary manager stated the required temperature of the oatmeal should be at 165 degrees. She stated she did not know why the temperature was much higher. The temperature log for 02/22/24 indicated the oatmeal was logged under cereal and the temperature was documented at 166 degrees. The Dietary Manager stated she did not how the oatmeal was logged at 166 degrees, but the test tray oatmeal had a temperature of 177 degrees, she stated that she did not know how it could be at 177 degrees. During interview on 02/22/24 at 9:02 AM the Dietary Manager stated that food temperatures are required to be taken at serving place before serving. The Dietary Manager stated that this failure could place resident at risk for cross contamination and food borne illness. She stated the Food warmer was set at 135 degrees to preserve temperature. The Dietary Manager stated she oversaw the temperature logs, if not her then, the cook in the morning or evening are trained to check food temperature log. She stated serving a tray with a temperature high could result in a resident being burned or harmed. During interview on 02/23/24 at 2:13 PM the Administrator stated the Dietary Director oversaw that policies are being followed. The Administrator stated staff are trained upon hire and as needed. The Administrator stated these failures could result in dissatisfaction of food served, cross contamination and foodborne illnesses. The Administrator stated she followed up with the Dietary Manager to confirm in-services were completed. Record review of In- Service Training Report Topic: Time/Temperature Control/ Logging Temperatures dated 7/21/22 conducted by Dietary Director and signed by all dietary staff. Record review of policy Food temperature, not dated, revealed 3. Record reading on Food Temperature (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675312 If continuation sheet Page 4 of 9 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 02/23/2024 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 0812 Chart (form 401) at beginning of tray line and end of tray line. 4. Acceptable serving temperatures are: Eggs, omelets 140 degrees- 155 degrees. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675312 If continuation sheet Page 5 of 9 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 02/23/2024 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed an adequately equipped system allowed residents to call for staff assistance through a communication system for 1 (Resident #45) of 8 residents reviewed for call light button placement. Residents Affected - Few The facility failed to ensure that Resident #45 ' s call light was functioning properly. This failure put residents at risk of not being able to call for assistance when needed. Findings included: Record review of Resident #45 ' s face sheet dated 02/20/2024 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #45 ' s admission Note dated 02/20/2024 revealed he had diagnoses including dementia, left hip surgery, urinary tract infection/ extended-spectrum beta-lactamase (enzymes or chemical produced by germs that make it harder to treat with antibiotics. It is a type of urinary tract infection). He had memory deficits, contact isolation and was on fall precautions, Record review of Resident #45 ' s baseline care plan dated 02/20/2024 revealed he needed extensive assistance from one person to bathe, for toileting and for walking. He required limited assistance from one person to move around in bed, and to transfer between surfaces. He was at risk of falling, and his call bell was to be in place. He had a cognitive impairment. The level or type of impairment was not specified in the care plan. In observation and interview on 02/20/24 at 09:57 AM, Resident #45 revealed he had been waiting a long time for someone to come to ask them to refill his water jug. He was not able to remember how long he had been waiting. When asked how he called for help he said he pressed the call light, which he then demonstrated. It was observed that the light on the wall (an indicator that the call light had been activated) did not light up, and observation of the light outside Resident #45 ' s room also did not light up. Resident #45 stated that the call light had not worked since the resident was moved to that room on 02/16/2024. In interview and observation on 02/20/2024 at 12:00 PM, C.N.A 1 was observed pressing Resident #45 ' s call light button and pushed the call light cord into the wall, with no change. C.N.A. 1 was observed to push Resident #45 ' s call light button again and went into the hall to see if the light went on. She stated that the call light was not working, and she needed to let the maintenance man know so he could fix it. C.N.A. 1 stated that she did not know that the call light had been broken and the resident rarely used it C.N.A. 1 stated the harms to a call light not working she stated that a resident could get hurt or have a serious accident. In an interview on 02/21/24 at 12:03 PM, the Maintenance Director said he had not heard anything from any of the staff in regard to a call light not functioning. The Maintenance director stated if there was an issue with something not working in a residents room he would correct it immediately. The Maintenance Director stated that the staff will add it to the maintenance log and he will review, fix, then add that it had been resolved. The Maintenance said not having a working call light put the resident at risk of not getting the help she needed. He said when something was broken a note could (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675312 If continuation sheet Page 6 of 9 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 02/23/2024 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few be put in a notebook at the front of the facility and usually maintenance staff would come down and get it fixed right away. The maintenance director stated that a new room should be checked by Maintenance and Housekeeping Director before a resident was moved in. During an interview on 02/21/24 at 11:10 AM with CNA 2, she stated the risk could be an injury if the residents are not able to use the call light for help. The resident still did not have a functioning call light. When asked how often the call lights should be checked if functioning, she stated every time the staff enters the room. If the call light is broken it is that person's job to go immediately to inform the maintenance and add it to the Work Order book. This interview related to the specific failure because this C.N.A. was working with the resident during the time that the call light was broken and had not noticed that the residents call light was broken or submitted a work order. The resident had a broken call light and it had been broken 02/16/2024 to 02/20/2024. During an interview with the Housekeeping Director on 02/21/24 @ 1:14 PM, she stated that she does not remember filling out those forms Guardian Angel Checklist forms), but that it was her writing, and she must have Just missed it. She state a residents residing in a room with a call light that was not working properly, could result in a resident being seriously hurt or ill because they cannot come out to ask for help like a regular resident at the facility. Record Review of the Maintenance logs from the dates 02/16/2024 to 02/22/2024 : There had not been a work order submitted since 11/2023. Record review of the housekeeping log from 02/26/2024 to 02/22/2024 : There had been forms completed by the Housekeeping Director stating that the room Resident #45 was transferred to for contact isolation was ready and there were no issues with the room. Record review of the facility Call Lights: Accessibility and Timely Response policy dated 02/2023 revealed, The purpose of this policy was to assure the facility was adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. Staff will ensure the call light was within reach of resident and secured, as needed. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident ' s room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675312 If continuation sheet Page 7 of 9 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 02/23/2024 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 0921 Level of Harm - Potential for minimal harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for one of one laundry room reviewed for environment. Residents Affected - Some -The facility failed to properly document the deep cleaning tasks that were performed for dates 02/22/24 and 02/23/24. The facility failed to properly document the Lint Collection tasks for dates 02/21/24 and 02/22/24. -The facility failed to properly scrub their hands for at least 20 seconds with soap and water to prevent cross contamination and infection. -The facility failed to properly dispose and maintain the lint accumulation in the facility dryers in a timely manner. This failure could put residents at risk for an unsafe environment. Findings include: Record review of the Laundry Deep Cleaning Chart on 02/23/24 at 11:53 AM indicated that the deep cleaning tasks had not been completed on 02/22/24 or 02/23/24. Record review of the Laundry Lint Trap Log on 02/23/24 at 11:52 AM indicated that the laundry lint trap cleaning had not been documented for the dates of dates 02/20/24 from 06:00 AM through 02:00 PM and 02/23/24 from 06:00 AM through 11:00 AM. Observation on 2/23/24 at 12:20 PM during the laundry room inspection, LS was observed to walk to the sink, scrubbed her hands with soap and water for only 9 seconds before rinsing her hands of soap and water and handling clean linen. Further inspection revealed the lint collector area beneath the dryer had large football sized clumps of lint accumulated on the electrical component at the top of the lint collector area. In addition, the Laundry Deep Cleaning Chart and the Laundry Lint Trap Log had not been completed. In an interview on 2/23/24 at 12:42 PM, the LS stated she had not gotten around to the Lint Trap Log yet today because she had been busy all morning. She stated, I have never seen that form (deep cleaning chart) before. She stated the lint was accumulated around the electrical outlet because, I don't touch anything up there. I don't want to break it, so I just leave it alone. She stated there could be a fire if the lint was not emptied out completely. LS stated, I don't remember the length of time I should wash my hands. She stated that germs could spread if hand washing was not performed correctly. In an interview on 2/23/24 at 12:20 PM with the HD, she stated she was going to be doing an in-service immediately with LS. She stated the LS had just started on 02/03/2024, and was nervous during the interview with the Investigator. The HD stated that the Laundry Lint Trap Log was to be filled out every hour immediately after the lint has been cleaned out of the lint collector. The Laundry Deep Cleaning chart should be filled out every day immediately after the task has been completed. The HD stated all staff are given in-services on hand hygiene monthly, and LS had just completed hers at the beginning of the month. HD stated the lint not being cleaned out properly could result in a fire (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675312 If continuation sheet Page 8 of 9 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 02/23/2024 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 0921 Level of Harm - Potential for minimal harm Residents Affected - Some in the laundry room. She stated the forms should be filled out properly to be able to facilitate keeping the laundry room clean and sanitized for the residents clothing. The HD stated not washing their hands properly could result in bacteria and infection spreading to the residents. In an interview with the Administrator on 02/23/24 at 01:13 PM, she stated the LS was new and just completed all her trainings recently. The Administrator stated she does not know why the LS could not demonstrate or speak about proper hand hygiene because they are in-serviced monthly on infection control. Record review of the facility provided Infection Control Policy from Laundry and Linen. (Revised January 2014) reflected, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Record review of the facility provided Hand Washing/Hand Hygiene policy dated Qtr 3, 2018 reflected, This facility considers hand hygiene the primary means to prevent the spread of infections .Use an alcohol-based hand rub for the following situations: g. Before and after separating soiled and clean linen at all times h. wash hands before handling clean linen k. After handling used dressings, contaminated equipment, etc. m. After removing gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675312 If continuation sheet Page 9 of 9