Health inspection·November 3, 2023

F 0600 Progress mobility as tolerated and Weight bearing as tolerated. Level of Harm - Immediate jeopardy to resident health or safety There were no orders from admission [DATE] to 09/22/23 that were specific to the Acute care hospital lifting restrictions and or the PT evaluation precautions. Residents Affected - Few Record review of Resident #1's Progress Note dated 09/08/23 at 7:31pm revealed a change of condition for Left [sic. RIGHT] shoulder swelling, he was sent to an Acute Care Hospital Emergency room. Record Review of the Acute Care Hospital emergency room After Visit Summary for Resident #1 dated 09/08/23 reflected he was seen in the ER for right shoulder pain and swelling. An x-ray was taken at 8:15pm and revealed total reverse shoulder arthroplasty dislocation (arm bone is not in shoulder socket). Per ED physician note it stated replaced shoulder appears to be dislocated anteriorly (behind). Also, likely that this has been dislocated for days. Aftercare directions read: Do not lift anything, do not push, or pull things, do not lift arm above shoulder and follow up with orthopedic surgeon on Monday (9/11/23). Record review of the Physician Order Recap Report for Resident #1 from 09/08/23 to 09/22/23 revealed there were no orders with post dislocation restrictions, limitations, or aftercare. Record review of the Orthopedic Follow-up dated 09/22/23 revealed Resident #1 had decreased range of motion since last visit, pain along the right shoulder, and deformity at the shoulder. X-ray completed during follow up revealed an anterior dislocation of his reverse total shoulder prosthesis. Due to this dislocation, it was noted that Resident #1 will require revision surgery of the right shoulder. Record review of Resident #1s Physician Order Recap Report dated 09/22/23 to 10/08/23 revealed the following orders: Monitor sling in place to right shoulder every shift for post-op care with a start date of 09/22/23 and an end date of 10/08/23. non-weight bearing to right shoulder and sling is in place every shift for dislocation with a start date of 09/22/23 and an end date of 10/08/23. Record review of Resident #1s Acute Care Hospital After Visit Summary dated 10/9/23 to 10/9/23 revealed that he was admitted for dislocation of prosthetic joint shoulder and had surgical interventions during this stay. He was discharged with the following restrictions: non-weight bearing to operative extremity, no lifting with operative extremity, no shoulder range of motion ok to gently straighten and bend elbow, keep sling on at all times, progressive mobility as tolerated, and no driving. Record review of Resident #1's Physician Order Summary Report dated 10/25/23 revealed an order that stated Keep sling on at all times except during shower or bathing with a start date of 10/10/23. No lifting with operative extremity, contact PCP for any distress or questions concerns, SOB, chest pain with a start date of 10/10/23. No shoulder range of motion allowed it is ok to gently straighten and bend the elbow with a start date of 10/10/23. Non weight bearing to RUE (right upper extremity) with a start date of 10/09/23. Use mechanical lift for all transfers with a start date of 10/09/23. Interview on 10/25/23 at 11:32am with Resident #1 revealed he needed a lot of help taking care of himself since he was first admitted on [DATE]. He stated he cannot use his left arm because of a past stroke and his right side he could not use because he just had surgery on his shoulder. He stated he needed help to move in bed, to transfers to the wheelchair, and to wash up because both his right and left arms were not functional. He stated some time before he went to the ER on [DATE] he was rolled on his right shoulder during ADL care, and it felt loose after that. He stated he has swelling (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675272 If continuation sheet Page 2 of 10 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 675272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willowbend Nursing and Rehabilitation Center 2231 Highway 80 E Mesquite, TX 75150 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 0600 and pain and that's when he asked to be sent to the hospital. Level of Harm - Immediate jeopardy to resident health or safety Interview on 10/25/23 at 2:15pm with CNA J revealed he was not aware of any limitations or restrictions Resident #1 had for his right shoulder. He stated he cared for resident between 09/04/23 and 09/22/23. During that time, he provided care to resident by himself (one person assistance) with bed mobility and transfers. He stated he did not receive any information from the facility about Resident #1 not being able to assist with his ADLs. He stated Resident #1 would help with ADLs by pulling himself over, using the side rails and he would feed himself and help transfer to his motorized scooter and once in the scooter he would smoke using his affected arm. He was unaware of where he could find patient care specific information like how to transfer them or if they were incontinent, he stated he would ask the nurse. Residents Affected - Few Interview on 10/25/23 at 3:25pm with CNA K revealed Resident #1 would use his right arm for things like eating or moving around in bed or to assist with ADLs like rolling to the side to remove soiled linens from underneath him. She was unsure of any restrictions or limitations that he had with the right arm. She was unsure if Resident #1 was cleared to bear weight or use the right arm for ADLs. She stated if a new resident were admitted she would ask the nurse how to transfer them and how much help they needed. If resident were to have any restrictions she would ask the nurse, and there was no physical place this information could be found. Interview on 10/26/23 at 2:39pm with CNA L revealed Resident #1's ADLs could be performed with one person when he first got here. He would use the right arm all the time to help roll over by grabbing the side rails. She stated she was not aware of any restrictions or limitations he had for the right arm, and he used to do everything. She stated if she needed to know how to care for a resident, she would ask the nurses to see how they transfer, eat or how many people were needed to care for them. She stated if she had a new admission, she would have to wait for the nurses to check on the resident so they can gather the plan of care information. Interview on 10/26/23 at 1:49pm with LVN M revealed that Resident #1 was a one person assist with ADLs when he was first admitted . She stated he had more use of the right arm, and he could feed himself and use his motorized wheelchair on his own. She stated she could not recall if he had any orders that would restrict him from using the right arm. She also stated the CNAs get instructions on how to care for the residents by word of mouth from the nurses or the therapy department. She stated with new admissions the nurses were responsible to transcribe the medication orders and send them to the facility doctor to verify. From there she stated medical records picked up the after-visit summary to upload it for the department heads to review for accuracy. Interview on 10/26/23 at 2:18pm with RN N revealed Resident #1 was receiving care with one person assist when he was first admitted . He would utilize his right arm to help with bed mobility by pulling himself over, using the side rail, he would stand and pivot transfer using his right arm to pull up and hold on to the nurse or CNA transferring him to the wheelchair. She also stated that he did not have any restriction with the use of his right arm. She stated when a resident was newly admitted , the CNAs would have to ask the nurse for the details on how to care for the resident and there was no place the CNAs would be able to find how to transfer the residents or any patient specific care information. The information was relayed verbally. She also stated the charge nurse was responsible to input all the orders and then turn in the after-visit summary to medical records takes the paper works to upload it, she was unsure who checked it from there. In an interview on 10/25/23 at 4:12pm with the DSD revealed the facility did an in-service training (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675272 If continuation sheet Page 3 of 10 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 675272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willowbend Nursing and Rehabilitation Center 2231 Highway 80 E Mesquite, TX 75150 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few for the CNAs and nurses on proper transfers due to Resident #1 stating he was not transferred properly. She was not aware of any further complications that came from the improper transfer and was only aware of the request to facilitate a hands-on training for the nurses and CNAs given by the therapy department. That in-service was completed on 09/22/23. Interview on 10/26/23 at 9:30am with the DOR revealed there was an in-service training held by his department as requested by the nursing department. He stated the training was provided to all CNAs and nurses and was on how to use the Hoyer lift and proper transfers. He stated the training was provided in mid to end of September 2023 and he was unsure of any concerns leading to this training request. In an interview on 10/26/23 at 9:40am with DON C revealed the facility decided to do in-service training after Resident #1 returned from the orthopedic follow up visit on 09/22/23 where it was revealed the resident's shoulder was dislocated. There was no disciplinary action for the staff due to being unable to determine when or how the shoulder became dislocated. During an interview on 10/26/23 at 9:54am with DON D revealed restrictions and limitations were put into place for Resident #1 after she spoke with the orthopedic surgeon following the follow-up appointment on 09/22/23. She stated there were no disciplinary actions for staff due to there being no limitations in residents' chart until 09/22/23, so they were following the proper orders. After 09/22/23 Resident #1 was non-weight bearing, bed rest, and was Hoyer transfer only. She stated she was not sure if rolling onto the right shoulder or using the right arm to pull bodyweight to once side was considered wight bearing. She stated there were no restrictions in place from 09/04/23 to 09/22/23 because there were no orders to do so. An interview on 10/26/23 at 10:15am with Administrator B revealed after her investigation initiated on 09/22/23, Resident #1's sheets were being changed during incontinent care and he was rolled to the right side and his shoulder felt different, but no pain was associated, so the CNA that rolled him to his side was reassigned, and concerns were noted to be a customer service issue that was resolved by moving the CNA from having Resident #1. She was not aware of any restrictions or limitations Resident #1 had to the right shoulder and if there was any it would be in his orders in the EMR. An interview on 10/26/23 at 12:57pm with DON D revealed Resident #1 was one person assist with ADLs including transfers and bed mobility from 09/04/23 to 09/22/23. She stated the MDS reflected two-person maximal assistance which was the wrong level of care for Resident #1 because it was the highest level of care, he received during the lookback window. She stated the charge nurses were responsible to input all the orders and notify the doctor for review and once that was done then the DON was the one who checks the after-visit summary to make sure the orders were input correctly. She stated the CNAs had access to information on how to care for the resident properly in the EMR but many of them do not utilize this system and get the information from the nurse's word of mouth. An interview on 10/30/23 at 4:10pm with the Orthopedic Surgeon Office Manager revealed Resident #1 had his initial surgery on 07/27/23. The resident was non-weightbearing and was ok to participate in therapy with specific stretches that did not include bearing weight to the right shoulder. She stated the heaviest thing that would be allowed was a coffee cup. She stated the only range of motion that was approved was gentle non-weight bearing, supporting his own weight on the shoulder, pushing, pulling or any resistance applied to the shoulder was not approved during the healing process. An interview and record review on 10/31/23 at 11:58am with DON D revealed Resident #1's shoulder (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675272 If continuation sheet Page 4 of 10 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 675272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willowbend Nursing and Rehabilitation Center 2231 Highway 80 E Mesquite, TX 75150 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few was not known to be dislocated until after his orthopedic appointment on 09/22/23. A record review was completed with DON D of Resident #1's ER After Visit Summary. The discharge diagnosis of shoulder dislocation and the x-ray results which showed his right shoulder was dislocated were reviewed. She stated she was not the DON at the time this occurred, and DON C would have more information. Interview on 10/31/23 at 12:27pm with DON C revealed, after reviewing Resident #1's ER After Visit Summary dated 09/08/23, it was revealed that his right shoulder was dislocated. She stated it was not reported to the facility physician or the orthopedic surgeon because the ER doctor already told the orthopedic doctor while Resident #1 was in the ER. She also stated she felt it was a complication from the previous surgery. She stated a shoulder dislocation should be considered a change of condition and she was not sure if the care plans or orders were updated. Record review of the After Visit Summary dated 09/04/23 conducted with DON C revealed that Resident #1 had lifting restrictions orders that were not put in to the EMR. She stated that the DONs and ADONs were responsible to make sure the information was accurate after admission. She was not sure why Resident #1s restrictions were missed on admission. She stated the potential harm to the residents could be them not getting the right care if orders were missed. Record review of the policy titled Admission, Transfer and Discharge Rights, admission Practice revealed the facility shall provide uniform guidelines in the admission of residents and admit residents who can be adequately cared for by the facility. Record review of the policy titled Safe Transfers revealed the following guidelines to ensure safe transfers included knowing the residents' abilities and limitations. The transfers status can be found in the [NAME] in PCC and POC which it is labeled care instructions. Review of the Resident Rights Policy Subject: Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment with revision date of 11/28/2017 reflected: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to, Facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675272 If continuation sheet Page 5 of 10 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 675272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willowbend Nursing and Rehabilitation Center 2231 Highway 80 E Mesquite, TX 75150 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 - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for one (Main Dining Room) of two dining rooms reviewed for environment. The facility failed to have an effective maintenance communication system for when items needed to be repaired or discarded, which resulted in a very large accumulation of medical equipment, appliances, furniture, clothing, and miscellaneous boxes in the Resident's Main Dining room. This failure could place residents potentially at risk of tripping, falling, choking or cross contamination, which could cause injury, pain, distress and gastro-intestinal illnesses and result in a decrease in their health and psycho-social well-being. Findings included: Observation on [DATE] at 10:35 am revealed, approximately 10 residents were doing an arts and crafts activity in the southeast and northeast side of the main dining room. On the southwest side of the main dining room, there was one broken manikin laying naked and missing both arms on the floor with 2 white pads on its stomach and a blue hospital gown was on top of the chair next to the mannequin. There were five large clear bags of clothes and bed sheets on top of the medical equipment and other items. There were two black wheelchair leg rests, a black storage caddy with small items in it, a small broken computer stand, a large metal grey and beige 2 passenger car simulator and red metal stand had two long cobwebs on it. There were four large boxes of unassembled beds on the floor and two more large boxes of unassembled beds leaning against several chairs. There was one bed with no mattress which was dusty with debris on it and 16 smaller unopened boxes and a black, grey, and green vacuum cleaner next to a black exercise bike. There was one small box with a white/greenish throw pillow and small items and a plastic blue and grey wheelchair cushion was sitting on top of a little box. There were two short brown night stands and one tall brown armoire and one tall dark brown microwave [NAME] against the wall. On the northwest side of the main dining room, there was a large empty metal clothing rack with a clear trash bag tied on the top rack. There were five meal carts that were 3 feet away from the kitchen entrance door and on the other side of the meal carts there was one broken bed 1 inch away from the meal carts with no mattress. Next to this bed there was another bed with no mattress that had one small brown nightstand and one beige blanket on it. Both of these two beds appeared dirty with several layers of dust and debris on them and there was a small metal ice maker covered in plastic on top of one of the tables. Next to the exercise bike, there was two square dining room tables that had what appeared to be whitish water stain splash marks and dust and debris on them. Interview on [DATE] at 10:43 am, the Dietary Director stated the electrical beds, bags of resident's clothes and end tables had been in the dining room for 2 days. She stated the end tables were going to be thrown away and was not sure how long the nurses' training Manikin had been in the dining room. She stated the 2-passenger car simulator equipment had been in the dining room forever and stated she guessed the old furniture came out of the resident's rooms. She stated the Maintenance Supervisor was putting together new furniture to place in the resident's rooms. She stated they had three privacy dividers that was supposed to separate this area from the other side of dining room, but you could still see the equipment and furniture from where the residents ate their meals. She stated between 12 -15 residents usually came to the dining room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675272 If continuation sheet Page 6 of 10 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 675272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willowbend Nursing and Rehabilitation Center 2231 Highway 80 E Mesquite, TX 75150 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 - Minimal harm or potential for actual harm Residents Affected - Some Interview on [DATE] at 10:53 am, the Maintenance Supervisor stated he had been putting stuff on the other side of the dining room just recently and did not have an answer as to why they were putting all of those items in there. He stated the beds in the boxes were delivered a week ago that would eventually go to rooms once they were put together. He stated the 2-car passenger car simulator and exercise bike had been on the other side of the dining room for a week in the dining room and he was not sure who put those in there. He stated the large bags of clothes, the broken manikin and vacuum cleaner, he would have to ask who put those in the dining room. He stated the two squared tables were going to be cleaned and put on the other side of the dining room and the 3 broken beds were going to the trash bin. He stated there was 1 hospice bed a hospice company was supposed to come pick it up. He stated he guessed it was cross contamination if the beds were close to the resident's meal carts. He stated he had one storage room in the back of the building but could not put this stuff in it because it was too small. He stated the facility did not have any other storage areas to put things in. He stated he was not sure why some of this stuff was in the dining room, but it would be gone today ([DATE]). He stated he spoke to one of the Therapist three days ago about what needed to be done to the equipment in the dining room and was not sure if it was trash or needed to be repaired and would go talk to them right now. He stated he was not responsible for the storage of equipment and furniture because He just gets rid things and added it was a little bit of everyone's responsibility for storing things and letting him know when things needed to be fixed or thrown out. Interview on [DATE] at 11:18 am, the Assistant Director of Rehabilitation stated the 2-passenger car simulator was broken because it did not move up or down any longer and had been in the main dining room for the past few months. She stated she was not sure who took it to the dining room. She stated they had a small therapy closet with wheelchairs and other small equipment and did not have any room for any other equipment. She stated she thought most of the items in the dining room mainly needed repair or refurbishing. She stated the exercise bike needed to be repaired and said the Maintenance Supervisor should know more about what needed to be repaired and thrown out. She stated the facility had an outside shed and did not know much about it. Interview on [DATE] at 11:36 am, after the Dietary Supervisor looked at the meal carts next to the two beds, she stated there was a risk of cross contamination of the meal carts because they were too close to the broken beds that were dirty. She stated the small ice machine in the corner had never been used since she started working here 2 years ago and it needed to be given away or thrown out. She stated when something needed to be repaired or thrown out, she notified the Maintenance Supervisor to assist and was not sure who brought in all of the furniture, clothes and equipment. Interview on [DATE] at 11:39 am, Dietary Aide E stated since working here for the past 6 or 7 months, the two-passenger car simulator and exercise bike had been in the dining room for a long time and was not sure how long. She stated she noticed all the other stuff in the dining room about 2 weeks ago and said the meal carts were always parked there and the two broken beds was just put next to the meal carts two days ago. Interview on [DATE] at 11:47 am, the Director of Rehabilitation stated the medical equipment and supplies were either broken or out of warranty and could not be fixed. He stated he did not move the two-car passenger simulator to the dining room and was not sure who did because it was in there since he worked at the facility for the past 4 months. He stated he was not sure who put the exercise bike in the resident's dining room, but it had been in them for a month. He stated the exercise bike had a technical problem and would not charge and added he would talk to the Maintenance Supervisor to see If he could fix it. He stated when equipment broke the Maintenance Supervisor fixed it or threw it out and was not sure how long the clutter had been in the dining room. He stated they only had a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675272 If continuation sheet Page 7 of 10 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 675272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willowbend Nursing and Rehabilitation Center 2231 Highway 80 E Mesquite, TX 75150 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 small medical equipment room they stored wheelchairs in and did not have any room for anything else. Level of Harm - Minimal harm or potential for actual harm Interview on [DATE] at 12:00 pm, the Maintenance Supervisor stated he contacted someone who was on their way to pick up the broken items and they should be to the facility shortly. Residents Affected - Some Observation on [DATE] at 12:44 pm, the Maintenance Supervisor was observed taking some equipment from the main dining room and putting them into a white pickup truck. Observation on [DATE] at 1:15 pm, in the main dining room there were 13 residents eating their meals with two CNA's and one nurse present and there was several pieces of equipment, furniture and unopened boxes on the other side of the main dining room that could still be seen around the sides of the two privacy curtains. Interview on [DATE] at 2:46 pm, Dietary Aide F stated he noticed beds, wheelchairs, the manikin, dressers in the main dining room for a while. He stated all of that stuff in the dining was a cross contamination issue and said he asked the Dietary Director, why was all that stuff in the dining room and she said she spoke to the Maintenance Supervisor about it, but he had not done anything about it yet. Interview on [DATE] at 2:54 pm, Dietary Aide G stated for the past 3 weeks he worked at this facility he noticed a side of the main dining room had mostly tables, beds, and was full of old furniture and equipment. He stated the equipment and furniture was moved yesterday ([DATE]) out of the dining room and was glad they did it. He stated that stuff needed to be taken out so that the residents could start eating on both sides of the dining room. He stated the dining room needed to be nice for the residents because this was their home. Interview on [DATE] at 3:04 pm, [NAME] H stated the furniture and equipment should not be stored in the dining room and they needed to be stored somewhere else because this was the residents dining room where the residents ate. He stated he had not noticed the cabinet door was missing in the dining room. He stated when something was broken, he wrote it into the maintenance logbook and if still was not resolved he took it to a higher authority, the Dietary Director. Interview on [DATE] at 3:15 pm, the Dietary Director stated all the old stuff in the dining room was taken to the dumpster and hospice came and picked up the bed in the dining room. She stated when kitchen equipment needed to be repaired, she reported it directly to the Maintenance Supervisor to fix and said there was a storage shed behind the facility with a plate warmer and refrigerator in it. She stated she knew the furniture did not to belong in the dining room and should be kept in the storage shed in back of the building. She stated she was not sure why these items were not stored back there already and said once the dining room was cleared of all the items, she was going to deep clean it so that the residents could go on that side of the dining room also for meals. She stated the cabinet door in the main dining room had been broken for some months and had not spoken to maintenance because she forgot to do but she was going to notify the Maintenance Supervisor today [DATE] to fix it. Interview on [DATE] at 4:56 pm, DON D stated they received some new beds two weeks ago and the Maintenance Supervisor was putting them together. She stated over 6 weeks ago she noticed a lot of junk in the dining room, but there was only so much she could do, and some things fell through the cracks. She stated they had a little shop building to store things in the back of the facility. She stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675272 If continuation sheet Page 8 of 10 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 675272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willowbend Nursing and Rehabilitation Center 2231 Highway 80 E Mesquite, TX 75150 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 - Minimal harm or potential for actual harm Residents Affected - Some a year ago she told the Maintenance Supervisor to get rid of the 2-passenger car simulator, to haul that crap because nobody used it. She stated the dining room should not be a storage area and noticed the bags of clothes and exercise bike in the dining room yesterday [DATE] and then told the Maintenance Supervisor he needed to make rounds in the dining room to make sure the area was safe and clean. She stated she and the Administrator would start monitoring that area because having those items in the dining room could be a safety risk that could cause a resident trip or fall. She stated there should not be medical equipment in the dining room because they had a storage building outside and added the Maintenance Supervisor was responsible for the maintenance and storage of items. She stated she wanted to make it nice and pleasant looking for the residents and if something was not used it should be thrown out. Interview on [DATE] at 5:30 pm, Administrator A stated working here a year but had been on medical leave. He stated being aware of the medical equipment and bedding furniture in the dining room but was unaware of the bags of clothes and training manikin in there. He stated there were dividers usually up to hide the items but said anytime something was an eye sore and not in the storage room should be thrown away. He stated they were getting rid of those items in the dining room because there was no point of hanging on to something they were not going to repair. He stated they had an offsite storage area and was not sure why it was not being used and added he had not ever gone to look inside of it to see what was in it. He stated the Maintenance Supervisor was responsible for the maintenance and storage of equipment and other items and ultimately, he said he was responsible for ensuring they stored old equipment and furniture in another location. He stated he was not sure why all of those items had not been moved or trashed and suspected there were other priorities that caused the delay. Interview on [DATE] at 2:34 pm, CNA I stated she noticed for one or two months the clutter in the dining room and was told they needed to put the new beds together to give to the residents. She stated she noticed bags of clothes of deceased residents in the main dining room also and said for almost a year that side of the dining room was a training area for the employees. She stated having all those things in the dining room was dangerous because the residents ate in there and she had not seen residents over there, but they could walk or wheel their wheelchairs to that side of the dining room and could fall. She stated she kept telling the Maintenance Supervisor about moving those items out of the dining room and he would say okay. She stated having those items in the main dining room was also cross contamination. Interview on [DATE] at 4:12 pm, the Maintenance Supervisor stated he threw out a lot of the equipment and clothes last Thursday [DATE] that were in the main dining room. He stated the plan to prevent items from being stored there again was he would closely watch the main dining area and trash any items put there. He stated there was 1 bed needing a motor he fixed last week and no longer in the dining room. He stated the facility had a storage unit, but it was too small and had too much stuff in it to put the boxes of new beds and other items inside of it. He stated they did not have any other areas to store things needing to be fixed and said he was going to talk to Corporate about getting a larger storage area to put the new beds they received and for other items needing repair. He said there was a lot of clutter in the dining room and those items should not have been in there. Observation on [DATE] at 9:39 am, the Southwest side of the main dining room had five large boxes of unassembled beds and three smaller unopened boxes and talk dark microwave cart. The northwest side of the main dining room had one dining room table and two chairs. Record review of the Facility's Maintenance Policy dated [DATE] revealed, Policy: It is the policy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675272 If continuation sheet Page 9 of 10 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 675272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willowbend Nursing and Rehabilitation Center 2231 Highway 80 E Mesquite, TX 75150 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 - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete of this facility to establish procedures for routine and non-routine care of equipment and to ensure that equipment remains in good working order for resident and staff safety .Procedures .5. The Maintenance will check Maintenance log/System in the morning and prior to leaving for the day .6. If equipment requires repair other than routine maintenance or servicing, the vendor through which the equipment was purchased will be contacted and arrangements made for repair/replace .7. Equipment will be stored in a safe manner as to not become obstacles to residents in communal areas. Event ID: Facility ID: 675272 If continuation sheet Page 10 of 10