Health inspection·April 17, 2025

F 0561 Review of Resident #4's weight record revealed a 3.0% weight gain from 04/04/25. Level of Harm - Minimal harm or potential for actual harm In observation on 04/15/25 at 9:30 AM Resident #4 revealed she had no candy or snacksin her room. Four sodas were in a bottom drawer in her night stand. The gifts of lotions were on her night and the satin pillow cases were not on her pillows. Residents Affected - Few In an interview on 04/15/25 at 1:58 with Resident #4's Family Member #A, she said sent Resident#4 a gift to the facility for the resident's birthday, Family Member #A claimed she called the facility and found out the gift she send her was not given her mother and was held back due to a request from another family member. Family Member #B, requested the gift be held until she arrived in March. Family Member #A called the facility and found out from a staff member Residen t#4's candy was being held in one of the staff offices. Family Member #A also sent a Valentines gift with several hygiene items, and she also found out some of the items were held. Family Member #A claimed she had sent her some hair products, satin pillowcases, and candy. She was told that the candy was being held by Social Worker and Activities Directors office and her lotions were at the nurse's desk. Family Memeber #A was upset as she felt that her mother had no access to her treats, she had sent her and did not understand why they treats were being kept from her as she has no diet restrictions. In an interview on 04/16/2025 at 1:30pm Resident #4 stated that she did not have any of the candy or sodas her daughter had sent her. The resident stated she could not recall any other gifts other than her birthday gifts and did not get all her gifts from staff. The resident could not recall where her satin pillow cases were located as they were not on her pillows. In an interview on 04/16/25 at 2:05 CNA A she stated the satin pillowcases given to the resident as gifts were with laundry services to be washed . CNA A stated the resident has sodas in her nightstand drawer so that only she had access to them. CNA A remembered the gifts and soda but did not remember the resident having any candy in her room. In an interview on 04/16/25 at 4:01 pm with Business Office Manager she stated the mail is brought to the business office and then it is distributed to the residents unopened. The business office manger stated she had spoken with Family Member #B and was told to hold Resident #4's gift till she arrived in March. She stated Family Member #B goes often to see the Resident #4 so she did what was asked of her.The Business Office Manger stated family #A found out and asked for the gifts to be given to Resident #4 immediately. She stated the package was taken by the Activities Director and the Social Worker and was to be given to the resident. In an interview on 04/16/25 at 4:22pm with social worker she stated the gift was received in January and Family Member #B had asked staff to hold the gift till she arrived in March. Family Member #B oversees the resident's finances but Family Member #A has Power of Attorney over Resident #4. The social worker stated she and the activities director opened the gift so that the items could be inventoried and kept as the resident had plenty of candy and sodas already. When Family Member # A found out the gifts were kept from Resident #4, she ask to speak to the activities director or social worker to see why the gift were held from her. The activities direct took the gift to resident#4 and video chatted with Family Member #A to show Resident#4 opening the birthday gifts but the candies were kept in the office. The Social Woker stated the activities director used the candies from the birthday and Valentine's gifts as an incentive to motivate the resident to be more involved in activities around the facility. The social worker stated Family Member #A was sending large amounts of candy and soda that is why it was kept in the office. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675312 If continuation sheet Page 2 of 16 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 04/17/2025 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 0561 Review of the facility's Statement of Resident's Rights dated August 2022 reflected the resident is to be supported by the facility in exercising his or her rights Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675312 If continuation sheet Page 3 of 16 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 04/17/2025 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a PASRR evaluation was completed on newly admitted residents prior to admission or after admission for 1 (Resident #48) of 5 residents reviewed for PASRR screenings. Residents Affected - Few The facility failed to ensure Resident #48's PASRR L1 screening dated 12/10/24 accurately reflected his diagnoses of mental illness. There was no evidence that Resident #48 was referred to a Level 2 PASRR Screening and Evaluation. This failure could affect residents by placing them at risk for not receiving needed treatments and services. Findings included: Record review of Resident #48's face sheet revealed a [AGE] year-old male with an admission date of 01/22/25 and original and initial admission dates of 12/11/24. Diagnoses included major depressive disorder, recurrent, severe with psychotic symptoms, and mood (affective) disorder dated 12/13/24, unspecified dementia with mood disturbance dated 12/16/24. Record review of Resident #48's quarterly MDS report 03/17/25 revealed a BIMS score of 8 indicating moderate cognitive impairment. He was dependent on staff for all transfers. He required substantial assistance with toileting, lower body dressing, and footwear, moderate assistance with showering and positioning, supervision with upper body dressing and personal hygiene, and set-up with oral hygiene and eating. He utilized a wheelchair and could self-propel short distances. He was always incontinent of bladder and bowel. Record review of Resident #48's PL1 from a local hospital dated 12/10/24 was negative for MI (mental illness), ID (intellectual disability), and DD (developmental disability). There were no other PL1 screenings for Resident #48. Record review of Resident #48's Care Plan dated 12/11/24 revealed he was at risk for Activity Intolerance r/t major depressive disorder, severe with psychotic symptoms, and mood disorder Date Initiated: 12/16/2024 Revision on: 02/15/2025. He was at risk for Impaired Social Interaction r/t major depressive disorder, severe with psychotic symptoms, mood disorder Date Initiated: 12/16/2024 Revision on: 02/15/2025. He had a behavior problem of being accusatory r/t major depressive disorder, severe with psychotic symptoms, mood disorder. He places himself on the floor and crawls to the doorway or hallway Date Initiated: 12/13/2024 Revision on: 02/15/2025. He used anti-anxiety medications (Ativan) r/t Adjustment issues, Anxiety disorder Date Initiated: 12/16/2024 Revision on: 02/15/2025. He used psychotropic medications Ativan, Depakote, Fluoxetine r/t Mood disorder, anxiety, and mood disturbance Date Initiated: 12/13/2024 Revision on: 02/15/2025. He had a mood problem r/t Disease Process Major depressive disorder with psychotic features; yells and curses, removes clothing and presents himself naked to others, accusatory, places self on floor, and crawls on floor. Date Initiated: 12/13/2024 Revision on: 02/15/2025. Record review of Resident #48's mental health warrant dated 01/09/25 revealed he was transferred to a local psyche facility for assessment due to exposing himself to staff and did not have the urgency to cover up when visitors came including children. He yelled at staff and threw his briefs on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675312 If continuation sheet Page 4 of 16 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 04/17/2025 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 0645 Level of Harm - Minimal harm or potential for actual harm floor. He used his bed to urinate and defecated on and refused to leave his briefs on. He was verbally aggressive with staff and had no regard to other residents. He was combative with care and at times would not allow care. He threatened to leave (the facility) and kill himself by throwing himself out of the window. He was impulsive, refused medication, and tried to hit staff. The document was signed by the SW Returned 01/22/25 with no med changes and no new diagnoses. Residents Affected - Few In an interview with the MDS on 04/17/25 at 2:15 pm revealed Resident #48 was admitted from a local hospital on [DATE] with a negative PL1. She said they (the facility) submitted what the local hospitals provided. She said a Form 1012; Mental Illness/Dementia Resident Review (used to assist nursing facilities in determining whether a resident with a negative PASRR Level 1 Screening form needs further evaluation for mental illness, or when an individual's diagnosis was changed) should have been sent for Resident #48 because his diagnoses included major depressive disorder, recurrent, severe with psychotic symptoms, and mood (affective) disorder dated 12/13/24. She said she just missed it. The MDS said she would submit a Form 1012 today. She said a Form 1012 was for when a resident had a negative PL1 needed further evaluation for mental illness or if the diagnosis changed. In an interview with the SW on 04/17/25 at 2:18 pm, she said she just was not thinking about PASRR when everything was going on with him at the time she submitted a mental health warrant on Resident #48. She said the IDT worked as a group when a resident's behaviors were getting to be a problem. The SW said per protocol, if the resident was in the hospital within 30 days of their most recent admission date, they would not re-submit. She said the guideline did not specify if the PL1 should be resubmitted if there was a change within those 30 days. In an interview with the DON on 04/17/25 at 2:22 pm, she said Resident #48 was seen by psyche on 12/13/24. She said he returned from the local psyche hospital on [DATE]. She said there was no PL1 reinitiated as a positive after his return. Record review of the facility policy dated November 2016, titled, Patient Care Management System revealed under 7. Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASRR recommendations. If a facility disagrees with the findings of the PASRR, it must indicate its rationale in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675312 If continuation sheet Page 5 of 16 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 04/17/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 residents who entered the facility received care and treatment consistent with professional standards of practice to prevent pressure ulcers and a resident with pressure ulcers receives necessary treatment and service to promote healing and/or prevent further development of skin breakdown or pressure ulcers, for two (Resident #214 and Resident#50) of two residents reviewed for prevention and maintenance of pressure ulcers. Residents Affected - Few The facility failed to ensure Resident #214 and Resident #50, who were identified as at risk of developing pressure ulcers, received necessary treatment and services thru proper use of low air loss air mattresses, which was chosen as prophylaxis to prevent the development of or worsening of pressure ulcers. This failure could place residents at risk of developing pressure ulcers for worsening of existing pressure ulcers. The findings included: Record review of Resident #214's Face Sheet dated 04/15/2025 documented a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses of Sepsis, and history of traumatic brain injury. Record review of Resident #214's five-day MDS assessment dated [DATE] indicated Resident #214 -Had Indwelling catheter, genitourinary obstructive uropathy(a blockage in ther urinary track, occurs whe urine flow is impeded leading to urine backflowand potential kidney damage), malnutrition, respiratory failure, oxygen therapy, suctioning as needed Bipap/CPAP(Bilevel Positive Airway machine is a device that helps people breathe by providing air at different pressure levels when inhaling and exhailing /continuous positvie airway pressure a device used to treat sleep apnea and other breathing disorders by delivering a constan flow of pressureized air though a mask) -Was totally dependent for bed mobility, transfers, toilet use, and bathing -Was always incontinent or urine and bowel - Had one pressure ulcer at admission in the Coccyx area(located at the bottom of the spine, just below the sacrum) and was at risk of developing additional pressure ulcers -Skin/Ulcer Treatment: pressure reduce device for bed Record review of Resident #214's Consolidated April 2025 Care Plan indicated Pressure Ulcer Prevention Assess for appropriate footwear Date Initiated 04/11/2025. Barrier Cream Date Initiated 04/11/2025 Revision on 04/11/202; 5 Encourage out of bed Date Initiated 04/11/2025. Revision on 04/11/2025; Encourage to float heels as tolerated Date Initiated 04/11/2025 Revision on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675312 If continuation sheet Page 6 of 16 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 04/17/2025 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 0686 04/11/2025. Level of Harm - Minimal harm or potential for actual harm Pressure Redistribution Mattress Date Initiated: 04/11/2025 Revision on 04/11/2025; Therapy disciplines to screen, evaluate, and treat as indicated; Turn and reposition q 2 hours and as needed. Keep body in good alignment Date Initiated: 04/11/2025 Revision on: 04/11/2025; Use suspension devices, pillows, and/or wedges to reduce pressure on heels and Residents Affected - Few boney prominences Date Initiated: 04/11/2025 Revision on 04/11/2025. Record review of Resident #214's April 2025 Physician Orders indicated air mattress ordered 04/13/2025. Record review of Resident #214's April 2025 weight log indicated Resident #214 was 139 pounds. Record Review of -Resident #214's Wound Assessment Report dated 04/11/2025 indicated: -Wound Type: Pressure Ulcer -Wound Location: Coccyx: unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) -Date Wound Identified: 04/11/25, present at admission -Drainage: Exudate moderate (serous clear watery fluid, which is separated from solid elements) -Measurement = Length 8.5cm, Width 8.5 cm, depth-0 -Wound Bed: Epithelial Tissue: Boggy (tissue or area this is soft, spongy, and may feel wet to touch) -Wound Edges: Attached edges appears flush with wound bed or as a sloping edge -Surrounding Skin: Erythema (redness of the skin may be intense bright red to dark red or purple) -Fragile: skin that is at risk for breakdown Record review of Resident #214's Skin-Acute Care Plan dated 04/20/2025 documented Pressure Ulcer: unstageable Coccyx related to accident, decreased mobility, incontinence, friction/shear .Approach: Pressure relief device: Air Mattress; Reposition every two hours; Treatment as ordered . In an interview on 04/17/25 at 02:33 PM LVN A stated she was taking care of Resident #214 on Monday, 04/14/2025 and on Tuesday, 04/15/25. LVN A recalled Monday, 04/14/2025 going into his room reviewed all mattress control settings but could not recall what settings the bed was on. LVN A stated she took care of Resident #214 on Tuesday, 04/15/2025 but could not recall checking his bed settings on that day. LVN A stated she was trained on the air mattress on Friday, 04/11/25 when the mattress was set up. She stated not having the correct weight on the settings could cause a breakdown of the skin. Observation of Resident #214 on 04/15/25 at 9:06 AM revealed the resident was lying in bed on his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675312 If continuation sheet Page 7 of 16 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 04/17/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few back in 30-degree angle and was asleep. The bed had indicated Medline air mattress, and the pressure was set at max 400lbs. Record review of Resident #214's Change in Condition Report dated 04/15/25 documented Skin Status Evaluation noted a change in the condition of the residents skin pressure ulcer. New onset Grade 2 or higher-pressure ulcer/injury, or progression of pressure of ulcer/injury despite interventions. Unstageable pressure ulcer presents to Coccyx area wound bed exhibiting slough. And is unstageable due to necrotic(black/dead) tissue. Care Plan stated refer to specalized practioner for specialized treatment. Interview with the DON on 04/15/25 at 4:00 PM revealed she stated she was aware Resident #214 had a current pressure ulcer and was in use of a low air loss air mattress. The DON said Resident #214's mattress pump should be set at the correct setting according to the resident's weight. The DON said each nurse caring for the R #214, as well as the Treatment Nurse, should be checking the low air loss mattress and pumps at the beginning of and throughout their shift for correct settings as per the physician orders and or manufacturer instructions. The DON said the all staff in contact with the resident are responsible for ensuring and implementing these practices. The DON said the purpose of the low air loss mattress was to prevent and treat pressure injuries. The DON said if the mattress was set over R #214's weight, the mattress was too firm placing the resident at risk for pressure injury worsening or possibly acquiring a new pressure injury. The DON stated the resident was admitted with the pressure ulcer staged at unstagable and a diagnosis of sepsis the resident was admitted to hospital for wound debribment Review of the undated Medline Supra CXC Low Air Loss and Alternating Pressure Mattress Manufacturer Recommendations documented .Use for prevention and stage1 through 4 pressure ulcers; pump alarms to indicate low pressure, Adjustable to patients' weight for customized therapy, 300lb weight capacity .Directions for Use: .Pressure adjust knob controls the air pressure output. When turning clockwise the output pressure will increase. [NAME] versa for decreasing air pressure. Please consult your physician for a suitable setting . 2. Record review of Resident #50's Face Sheet dated 04/15/2025 documented a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of Alzheimer's disease unspecified, other amnesia, pain unspecified, restlessness and agitation, repeated falls, and history of falling. Record review of resident #50s quarterly MDS assessment dated [DATE] indicated Resident #50 -Had a Brief Interview of Mental Status of 01 (severe cognitive impairment) -Was totally dependent for bed mobility, transfers, toilet use, and bathing -Was at risk of developing pressure ulcers but does not have any pressure ulcers -Skin/Ulcer Treatment: pressure reduce device for bed and chair . Record review of #50's care plan revealed o Potential for Impaired Skin Integrity as evidenced by Braden Scale for Predicting Pressure Ulcer Risk High Risk for Pressure Ulcer Initiated on 04/15/2025. Educate resident and representative about the proper usage of pressure reducing devices Date Initiated: 04/15/2025. Evaluate skin integrity. Initiated on 04/15/2025. Low Air Mattress initiate on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675312 If continuation sheet Page 8 of 16 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 04/17/2025 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 0686 04/15/2025. Level of Harm - Minimal harm or potential for actual harm Record review of #50 physician's orders dated 04/15/25 revealed resident is to have weekly head to toe skin assessments and a low air loss mattress to be checked for proper functioning. Residents Affected - Few Observation of Resident #50 on 04/15/25 at 9:10 AM revealed the air mattress was set at 350lbs on her proactive mattress. In an interview with LVN #B on 04/17/25 at 9:54 AM she stated the air mattress for resident #50 was a preventive measure as she had pressure ulcers in the past. LVN#B stated she incorrect setting on the air mattress can contribute to a pressure ulcer getting worse. LVN B also stated if a resident is on preventive measure the incorrect setting can create new ulcers for the resident if the resident is at high risk for pressure ulcers. LVN she received training for air mattress settings about a week ago. Interview with the DON on 04/15/25 at 4:00 PM revealed she stated she was aware Resident #214 had a current pressure ulcer and was in use of a low air loss air mattress. The DON said R #214s mattress pump should be set at the correct setting according to the resident's weight. The DON said each nurse caring for the R #214, as well as the Treatment Nurse, should be checking the low air loss mattress and pumps at the beginning of and throughout their shift for correct settings as per the physician orders and or manufacturer instructions. The DON said the all staff in contact with the resident are responsible for ensuring and implementing these practices. The DON said the purpose of the low air loss mattress was to prevent and treat pressure injuries. The DON said if the mattress was set over R #214's weight, the mattress was too firm placing the resident at risk for pressure injury worsening or possibly acquiring a new pressure injury. Review of the undated Proactive Protekt Aire 6000 Pressure and Low-Air-Loss Therapy Mattress Replacement Systems Manufacturer's Instructions documented .Caution: Please cover the mattress with a cotton sheet to avoid direct skin contact and for the patient's comfort, Users can adjust the pressure level of the air mattress to a desired firmness by themselves or according to the suggestions from a health care professional. It is recommended to press Auto Firm on the panel when the mattress is first inflated. User can the easily adjust the air mattress to a desired firmness according to the patient's weight and comfort. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675312 If continuation sheet Page 9 of 16 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 04/17/2025 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, 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 storage, preparation and sanitation. 1. The facility failed to ensure non-stick pans were not missing the coating. The facility failed to ensure coffee cups and bowls were clean. The facility failed to ensure product were 18 inches from the ceiling in the walk-in refrigerator and freezer. The facility failed to ensure spices were not open to air. The facility failed to ensure the walk-in freezer did not have ice accumulation inside of it. The facility failed to ensure the FSM appropriately followed infection control practices when the FSM grabbed the top of resident dessert cups by top rims with bare hands, while passing out meal trays to 5 of 24 residents in the dining room during lunch on 04/15/25. 2. The facility failed to ensure the FSM appropriately followed infection control practices when the FSM grabbed the top of resident dessert cups by top rims with bare hands, while passing out meal trays to 5 of 24 residents in the dining room during lunch on 04/15/25. These failures could place residents who received meals and/or snacks from the kitchen and satellite kitchens at risk for food contamination and food borne illness. Findings included: 1. During the initial tour and observation of the kitchen on 04/15/25 at 8:35 am revealed 4 non-stick type pans with flaking and scrape marks in the coating. There were 58 of 58 coffee cups that were stained and scratched. There were 4 of 12 plastic bowls with what appeared to be hardened food substance on and in them. The dirty cups and bowls were on the clean rack. There were 10 of 19, 21-ounce containers of spices that were open to air. There were 5 boxes of product and 11, 1-gallon containers in the walk-in refrigerator that were stacked less than 6 inches from the ceiling. There were 7 boxes of product in the walk-in freezer that were stacked less than 6 inches from the ceiling. There was ice accumulation behind the fan/condenser and ice droplets on the ceiling of the walk-in freezer. In an interview with the FSM on 04/15/25 at 8:35 am, she said she had worked in her position at the facility for 2 years. She said the non-stick pans became bare of the coating due to wear and tear. She said the kitchen staff used metal utensils in the non-stick pans because they were not allowed to use plastic because plastic chipped off. She said she was trained that way by the former dietary manager two years ago. She said she followed rules, wrong or right. She said it was not right to have used metal utensils in non-stick pans. She said the right thing to do was to use plastic or rubber utensils in the non-stick pans because that kind of material would not scratch or harm the coating. She said the non-stick pans would be more expensive to replace than plastic or rubber utensils. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675312 If continuation sheet Page 10 of 16 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 04/17/2025 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 said food got stuck in the non-stick pans when the coating was scratched. She said bacteria could get stuck in the scratches on the non-stick pans, then the bacteria could transfer to the food, which would transfer to the resident's and make them sick. She said she did not know if non-stick coating was toxic, but the chips of it could get into the food and make residents sick. She said she had new cups to replace the stained and scratched cups but had not put them out yet. She said the dirty cups and bowls were on the clean racks and coffee cart that was being used for service. She said she did not know why she had not already removed the stained and scratched cups when she got the new ones. She said all kitchen staff was responsible for making sure dishes were clean before they were used, and she was ultimately responsible. She said she would not want to drink from the dirty coffee cups. She said the dirty bowls looked like they had old oatmeal stuck to them. She said the open spice containers were supposed to be closed at all times to ensure insects, dust, or moisture did not contaminate the contents. She said contaminated spices could change the flavor of the food and make residents sick. She said the boxes in the walk-in refrigerator and freezer were a lot less than18 inches from the ceiling. She said the stacked boxes were a fire safety hazard because they blocked the sprinklers. She said the ice droplets on the ceiling of the walk-in freezer were because it was in defrost mode. She said she knew about the ice build-up behind the fan in the walk-in freezer because she broke it (the ice) off whenever she cleaned the walk-in freezer. She said it (the ice build-up) was always like that. She said she had not notified the MS about the ice build-up in the walk-in freezer. She said the process for reporting kitchen needs was for her to tell the MS verbally. Observation and interview with the FSM and RD during dining services on 04/15/25 at 12:46 pm revealed 4 of the dirty cups had been used for service and drank from by some of the residents (unknown). The FSM said she did not know why the cups were on the resident's table and they had definitely been used. The RD said the dirty cups on the table should never have been used due to cross contamination and because of the potential to make resident's sick. During an observation of dining on 04/15/25 at 12:51 PM the FSM was observed grabbing dessert cups from the top of the lid while she passed out dessert to 5 of 25 residents. In an interview on 04/15/25 at 01:02 PM the FSM stated by grabbing the dessert cups from the lids, it could contaminate the dessert cups and make residents sick through cross contamination. The FSM stated she did not realize she was grabbing the dessert cups from the lid and was just handing them out to residents. The FSM stated she had just told the staff serving not to grab cups from the top only from the bottom. The FSM stated there is no official staff training for serving food to residents in the dining room. In an interview on 04/16/25 at 03:40 PM the DON stated staff should not grab resident dessert cups from the top of the lids due to infection and cross contamination. The DON stated staff should grab the dessert cups from the side or bottom. The DON stated the last infection control in-service was done monthly and all staff are included. The DON stated the facility held a Skilled Fair on 02/5/25, and all staff were required to attend for hands on infection control training. In an interview on 04/17/25 at 11:58 AM the IP stated staff should not be grabbing any cups from the top because they could get their hands in the food and cross contamination could occur. The IP stated staff should be grabbing cups either underneath or on the side to avoid touching the rim of the cup. The IP stated infection control in-services are conducted at least once a month with all staff. In an interview with the MS on 04/17/25 at 3:53 pm, he said he worked at the facility for 11 years. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675312 If continuation sheet Page 11 of 16 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 04/17/2025 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 He said the process of getting kitchen repairs done was for the FSM to tell him verbally. He said there were no logs or electronic reporting system, just word of mouth. He said he was unaware of the ice build-up on the condenser fan box and ceiling of the walk-in freezer. He said he had seen boxes stacked in the walk-ins within a foot of the ceiling. He said stacking boxes within 6 inches of the ceiling in the walk-ins was a no-no. He said boxes stacked that high could cause a fire safety hazard by blocking the sprinklers should there be a fire. He said the boxes and containers should be only 18 inches from the ceiling. He said he never said anything to the FSM or kitchen staff or in-serviced them about the potential fire safety hazard. He said there was no way to track repairs because there were no logs for any repairs other than maybe emails. 2. During an observation of dining on 04/15/25 at 12:51 PM the FSM was observed grabbing dessert cups from the top of the lid while she passed out dessert to 5 of 25 residents. In an interview on 04/15/25 at 01:02 PM the FSM stated by grabbing the dessert cups from the lids, it could contaminate the dessert cups and make residents sick through cross contamination. The FSM stated she did not realize she was grabbing the dessert cups from the lid and was just handing them out to residents. The FSM stated she had just told the staff serving not to grab cups from the top only from the bottom. The FSM stated there is no official staff training for serving food to residents in the dining room. In an interview on 04/16/25 at 03:40 PM the DON stated staff should not grab resident dessert cups from the top of the lids due to infection and cross contamination. The DON stated staff should grab the dessert cups from the side or bottom. The DON stated the last infection control in-service was done monthly and all staff are included. The DON stated the facility held a Skilled Fair on 02/5/25, and all staff were required to attend for hands on infection control training. In an interview on 04/17/25 at 11:58 AM the IP stated staff should not be grabbing any cups from the top because they could get their hands in the food and cross contamination could occur. The IP stated staff should be grabbing cups either underneath or on the side to avoid touching the rim of the cup. The IP stated infection control in-services are conducted at least once a month with all staff. Record review of kitchen in-services dated 01/03/25 Dish Machine Cleaning, 02/20/25 Grease Fire Guidelines, 02/25/25 Cleaning Schedule, 03/04/25 Time Management/Food Carts, 04/15/25 Stained Cup ware/Bowls. Record review of the facility policy revised 03/19 titled, Food Storage revealed under #4. Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and bulk foods .11. Food is stored a minimum of 8 inches above the floor and 18 inches from the ceiling on clean racks or other clean surfaces .#14. All refrigerator units are kept clean and in good working condition at all times. Record review of facility's Infection Control policy dated February 2025 stated: 1. The facility must establish an infection prevention and control program (IPCP) that must include: a. A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. This applies to all Patients, staff, volunteers, visitors, and other (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675312 If continuation sheet Page 12 of 16 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 04/17/2025 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 individuals providing services under a contractual arrangement based upon the facility assessment. Level of Harm - Minimal harm or potential for actual harm References: FDA Food Code 2022 Ch. 4-202 Cleanability 4-202.11 Food-Contact Surfaces. (A)Multiuse FOOD-CONTACT SURFACES shall be: (1) Smooth; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. Ch. 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. 4-602 Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) Equipment food-contact surfaces and utensils shall be cleaned: (5) At any time during the operation when contamination may have occurred. (C) Except as specified in (D) of this section, if used with TIME/TEMPERATURE CONTROL FOR SAFETY FOOD, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned throughout the day at least every 4 hours. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675312 If continuation sheet Page 13 of 16 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 04/17/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 3 (Residenst #30, #34, and #55) of 4 residents reviewed for accuracy and completeness of clinical records. The facility failed to obtain and/or revise advanced directive orders for Residents #30, #34, and #55. This deficient practice could affect residents who require care and monitoring and place them at risk of receiving or not receiving advanced directives to meet their needs. The findings were: 1.Record review of Resident #30's face sheet revealed a [AGE] year-old female with an admission date of [DATE] and initial and original admission dates of [DATE]. Diagnoses included Diabetes, stroke with subsequent weakness on both sides and speech deficit, heart disease, depression, kidney failure, morbid obesity, schizophrenia, psychosis, impaired vision, and anxiety. Record review of Resident #30's quarterly MDS dated [DATE] revealed a BIMS score of 13 indicating intact cognition. She was independent with eating, required moderate assistance with upper body dressing, rolling left and right, sitting up, chair to bed transfers, and personal hygiene. She required substantial assistance with oral hygiene, toileting, and lower body dressing. She utilized a motorized wheelchair, was frequently incontinent of bladder and occasionally incontinent of bowel. Record review of Resident #30's care plan dated [DATE] revealed Resident #30 requested Code Status of: Full Code (perform CPR-cardiopulmonary resuscitation) Date Initiated: [DATE] Revision on: [DATE]. Record review of Resident #30's active physician orders revealed no code status ordered. There was no code status in her order summary or on her profile page. In an interview with the DON on [DATE] at 1:47 pm, she said Resident #30 did not have Advanced Directives for resident #30 and did not know how it could have happened because the care plans pulled from the physician orders. She said the facility transitioned to their electronic health record system starting on [DATE] and had been refining it ever since. She said advanced directives were reviewed on admission, during a care coordination meeting on ([DATE]) after admission, as needed, significant changes or a care plan meeting. She said the nurse managers reviewed the orders and the SW reviewed the code statuses of all new admissions and care plans and significant changes. She said the SW entered and inputs the advanced directive orders-she just missed it. The DON said she was responsible for overseeing accuracy and completion. She said she missed it too. She could not say how often advanced directives were reviewed. 2.Record review of Resident #34's face sheet revealed an [AGE] year-old female with an admission date of [DATE]. Diagnoses included respiratory failure, dementia, high blood pressure, and heart failure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675312 If continuation sheet Page 14 of 16 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 04/17/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #34's admission MDS dated [DATE] revealed a BIMS score of 09, indicating moderate cognitive impairment. She required supervision with eating, oral hygiene, and positioning in bed. She required moderate assistance with sitting up, lying down, and upper body dressing. She required substantial assistance with all other ADL's including transferring and mobility via wheelchair. She was always incontinent of bladder and bowel. Residents Affected - Few Record review of Resident #34's care plan dated [DATE] revealed Resident #34 requested Code Status of: Full Code Date Initiated: [DATE] Revision on: [DATE]. Record review of Resident #34's active physician orders revealed no code status ordered. There was no code status in her order summary or on her profile page. In an interview with the DON on [DATE] at 1:47 pm, she said Resident #34 did not have Advanced Directives and did not know how it could have happened because the care plans pulled from the physician orders. She said the facility transitioned to their electronic health record system starting on [DATE] and had been refining it ever since. She said advanced directives were reviewed on admission, during a care coordination meetings, after admission, as needed, significant changes or a care plan meeting. She said it was on her admission assessment dated [DATE] (confirmed). She said the nurse managers reviewed the orders and the SW reviewed the code statuses of all new admissions and care plans and significant changes. She said the SW entered and inputs the advanced directive orders-she just missed it. The DON said she was responsible for overseeing accuracy and completion. She said she missed it too. She could not say how often advanced directives were reviewed. 3.Record review of Resident #55's face sheet revealed a [AGE] year-old female with an admission date of [DATE] and original and initial dates of [DATE]. Diagnoses included obesity, stroke with subsequent inability to speak or swallow, anoxic (lack of oxygen) brain damage, gastrostomy tube, depression, anxiety, high blood pressure, heart failure, liver failure, convulsions (seizures), and history of sudden cardiac arrest. Record review of Resident #55's initial admission MDS dated [DATE] revealed a BIMS score of 00 indicating severe cognitive impairment. She was dependent on staff for all ADL's and required a mechanical lift for transfers. She could sit in a wheelchair but could not propel one. She was always incontinent of bladder and bowel. Record review of Resident #55's care plan dated [DATE] revealed Full Code dated initiated [DATE] and revised on [DATE]. Record review of Resident #55's active physician orders revealed no code status ordered. There was no code status in her order summary or on her profile page. In an interview with the DON on [DATE] at 2:27 pm, she said Resident #55's advanced directives were not on her profile. She said it was not in the physician orders. She said her Care plan coded her as a full code. She said it was missed by the SW and by reviewers including herself. She said if there was not a code status in the system, the resident would be a full code, even if their wishes were to be a DNR (Do Not Resuscitate). She said staff knew the resident's code status by looking at their profile or the physician's orders. She said Resident #55 did not have a code status ordered, so she would be a full code. She said every nurse that had seen her chart would have seen there was no code status, and no one brought it to her attention so she could have fixed it much sooner. She said the SW could input orders, but the nurses had to confirm the orders. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675312 If continuation sheet Page 15 of 16 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 04/17/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview with the SW on [DATE] at 3:39 pm, she said her role in advanced directives was to make sure they were in the charts and to ask the residents if they want to be DNR or Full Code. She said the nurses do it on the weekends. She said she thought she put Resident #55's advanced directive in her chart but she just missed it. She said the outcome could be that if something happened, there would be a lot of chaos. She said advanced directives defaulted to Full Code. She said if Resident #55 was a DNR, she would have gotten CPR against her and her family's will. She said there were a lot of people that saw that but did not make anyone aware. She said it was her responsibility. She said she must have missed Resident #30 and Resident #34's as well. Record review of the facility policy dated [DATE], titled, Advanced Directives revealed under #1. An Acknowledgement Receipt for Advance Directives/Medical Treatment Decisions must be completed for each Patient upon admission and upon any change in the status of the Patient's Advance Directives. #5. The Advanced Directive report must be reviewed daily for all Patients. The Social Worker or designee must verify the Advance Directive report for accuracy to ensure the clinical record reflects the current advanced directive status and use it to monitor the existence of a DNR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675312 If continuation sheet Page 16 of 16