Health inspection·January 17, 2024

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of Resident #1's orders, dated 12/28/23, reflected an order to consult with MD for wound care. There were no active orders for wound care. Record review of Resident #1's weekly skin assessment, dated 12/7/23, reflected he had multiple wounds to right leg, and an old wound to left heel. Record review of Resident #1's weekly skin assessment, dated 12/14/23, reflected he had multiple wounds to right leg, left toe and an old wound to left heel. Record review of Resident #1's progress notes reflected there was no further documentation about notification to the MD regarding the new wound found on Resident #1's left toe according to his weekly skin assessment on 12/14/23. Record review of in-service titled Weekly skin/ulcer assessment, dated 12/14/23, reflected all nurses were educated by the DON on weekly skin/ulcer assessments and notifying the RP and DON on changes. Record review of Resident #1's hospital records, dated12/28/23, reflected the resident was admitted to the hospital due to gangrene of his bilateral toes and lethargy. Resident #1 was diagnosed with osteomyelitis (inflammation of bone caused by infection) of right 3rd and 2nd toes, left great toes infection, chronic left heel ulcer, chronic anemia, severe tibia artery disease (circulatory disorder), and possible chronic kidney disease. Resident #1 had his left leg amputated below the knee on 12/21/2023 and his right leg was amputated below the knee on 12/26/23. Observation on 12/28/23 at 9:45 AM of Resident #1 at a local hospital, revealed he was lying in bed recovering from having a double below-knee amputation. Resident #1 was unable to be interviewed due to language barrier. In an interview on 12/28/23 at 9:46 AM, Resident #1's RP stated Resident #1 used a wheelchair for mobility; however, he was able to transfer independently and could do most ADLs independently. The RP stated Resident #1 was having a hard time adjusting to his limited abilities after having both legs amputated. The RP stated Resident #1 was active, able to communicate, and alert; however, when family visited him at the nursing facility on 12/28/23, he was disoriented, non-communicative, and did not recognize anyone. The RP stated it was then he noticed the toes on both of Resident #1's feet had turned black and once they complained to the nursing staff, Resident #1 was transported to the local hospital. The RP stated the nursing facility had not reported any changes in Resident #1's condition to him. In an interview on 12/28/23 at 10:28 AM at the local hospital, MD A stated he was the attending MD for Resident #1. MD A stated Resident #1 was admitted to the local hospital in 02/2023 due to wound infections with interventions which included debridement and antibiotic treatment. MD A stated Resident #1's recent amputation of both legs was due to infection and gangrene of multiple toes. MD A stated due to Resident #1's history he could not determine Resident #1's current condition was due to neglect by the facility without knowing information about treatment he was receiving at the facility; however, MD A stated Resident #1's age and diagnoses could have caused the infection to worsen rapidly, within less than a week without treatment. In an interview on 12/28/23 at 12:07 PM, LVN D stated she worked at the facility for 2 months. She stated she usually only worked the weekends but started working during the week about two weeks ago, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675272 If continuation sheet Page 2 of 15 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 01/17/2024 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 0580 Level of Harm - Immediate jeopardy to resident health or safety while the facility's full-time wound care nurse was out. She stated she did wound care on Resident #1's left shin, and her last time providing care to him was a month ago because the wound was resolved. She stated she did not do wound care on Resident #1's feet because he did not have wounds on his feet at the time. She stated she knew because it was protocol to assess the feet when doing wound care on his legs. LVN D also stated she would check the orders and treatment assessment records to check for other treatments the resident needed, and he was not receiving any other wound care. Residents Affected - Few In an interview on 12/28/23 at 12:48 PM, the DON stated she worked at the facility for about 3 weeks. She stated LVN C documented on 12/14/23 on Resident #1's weekly skin assessment he had a wound on his left toe that was not there the week prior. The DON stated LVN C informed her she did not notify the MD or report it to anyone because she thought the wound was already being treated. The DON stated her expectation was for the nurses to document any changes to the residents, check the orders for treatment and notify herself, the MD, and RP. The DON stated there were a lot of residents in the facility with wounds, so she had already provided an in-service on skin assessments and notification to all nurses on 12/14/23 as a precaution and prior to being aware that Resident #1 had a new wound. The DON stated LVN C received the training and still failed to notify anyone of Resident #1's new wound. The DON stated LVN C was terminated for failing to follow the facility's policy. In an interview on 12/28/23 at 1:37 PM, CNA E stated he worked at the facility for four months. He stated he worked with Resident #1 and the resident often refused showers and other care. CNA E stated about a week prior to 12/18/23, when Resident #1 was transferred to the hospital, he noticed Resident #1 was not eating and had severe diarrhea. CNA E also stated Resident #1 had a bad odor that smelled like it was coming from a wound. CNA E stated he reported this to the charge nurse, who was LVN C, and she stated she would notify the MD. CNA E stated he did not know if it was reported to the MD. In an interview on 12/28/23 at 2:25 PM, MD B stated she was one of the attending MDs at the nursing facility. She stated she typically saw Resident #1 once a month unless there was an issue. MD B stated Resident #1 admitted to the facility in 02/2023 with an infection in his foot after being treated at a local hospital. MD B stated it was recommended at that time Resident #1 have an amputation due to being high risk for infections, but his family declined, and Resident #1 was treated with IV antibiotics. MD B stated Resident #1 was also seeing a wound care specialist outside of the facility and his wounds had healed. She stated he would have intermittent wounds on his shins/legs from bumping them, but overall, he healed to her knowledge. MD B stated Resident #1 did not have any active orders for wound care, but she would have given one had she been notified that it was needed, especially due to Resident #1's history and comorbidities. MD B stated it was her expectation for the nurses to notify of any changes to her, and they were usually good about doing so. She stated she was not in front of the charts, but she could not recall being made aware of a new wound on Resident #1's left toe prior to him going to the hospital on [DATE]. She stated her first-time hearing of any issues for Resident #1 was on the day he was sent to the hospital. In a further interview on 12/28/23 at 5:45 PM, the DON stated the risk of not notifying the MD of a change in condition such as a wound could be it leading to a severe situation like sepsis and potentially death. In an interview on 01/17/24 at 10:48 PM, the DON stated since the facility's failure, processes were put in place to ensure it did not happen again. The DON stated a skin sweep of all residents in the facility was started on 12/19/23, with no change in condition or major skin issues found. She stated all CNAs were in-serviced on 12/20/23 on conducting skin assessments during ADL care and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675272 If continuation sheet Page 3 of 15 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 01/17/2024 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few reporting any skin issues or change of condition to the charge nurses. The DON stated further education with CNAs would include reminding them to also report concerns or change of condition to management, including herself, the ADONs, or the Administrator. The DON stated all CNAs were informed to document any skin issues found during showers on the resident's shower sheets and to also report everything to the nurse no matter when it was found. The DON stated all nurses were in-serviced on 12/20/23 on addressing change of condition immediately and reporting to the MD, DON, and RPs. The DON stated all staff were also in-serviced on 12/20/23 on reporting abuse and neglect. The DON stated she and the ADONs were conducting daily monitoring of skin assessments completed by the nurses to screen for new skin issues/change of condition and to monitor the condition of existing skin issues. The DON stated there would also be continuous education and reminders to all staff on the importance of skin assessments and immediately reporting any change of condition. The DON stated all CNAs and nurses were given skin assessment skills checkoffs to ensure their understanding on how to conduct them. The DON stated all nurses were expected to know how to assess all shades of skin for discoloration and wounds based on nursing skills obtain in nursing school. In an interview on 01/17/24 at 11:12 PM, LVN Q stated she was the full-time wound care nurse at the facility. She stated she worked with Resident #1 and last provided wound care to him on 11/7/23 when the wound on his right shin was resolved. LVN Q stated all of Resident #1's wounds had resolved and there were no new orders for wound care besides a standing order to consult with the MD for wound care of any new wounds. LVN Q stated she the nurses and CNAs had a good rapport with her and would usually inform her of new wounds and skin issues found on the residents. She stated the CNAs knew to inform the charge nurses of new wounds or any change of condition of the residents, but if they saw her in the hallways, they would inform her also. LVN Q stated she had not been informed that Resident #1 had any new wounds or a change of condition since 11/7/23 after all his wounds were resolved. LNV Q stated Resident #1 had dementia and was Spanish speaking only, so he would often refuse ADL care and not interact with staff due to confusion and language barriers. LVN Q stated she was able to communicate with him in Spanish so he would comply with her more; however, she was had not worked with him since 11/7/23. She stated she was also on vacation for two weeks starting on 12/15/23, which was during the time LVN C found the new wounds. LVN Q stated Resident #1 had already discharged from the facility when she returned to work. LVN Q stated she was never made aware of the new wounds to Resident #1's toes. She stated she also was not aware of multiple wounds on his right leg. LVN Q stated the only wound to Resident #1's right leg that she was aware of was the one she was treating on his right shin that was resolved on 11/7/23. LVN Q stated Resident #1 often had superficial scratches and scabs from bumping his leg on the wheelchair, but he did not have any active orders for wound care. In an interview on 01/17/24 at 12:46 PM, LVN R stated she worked PRN weekends at the facility and worked with Resident #1 on 12/17/23, the day before he was transferred to a local hospital. LVN R stated Resident #1 was acting his normal self and did not display any signs of pain or discomfort. LVN R stated the CNA did not report any change of condition of Resident #1 to her. She stated Resident #1 did not have diarrhea or a change in appetite on 12/17/23 or anything that needed to be reported to the MD. LVN R stated she was not aware of any new wounds that Resident #1 had. She stated she remembered an old wound that Resident #1 had on his left ankle or foot that had been resolved, but no new wounds. LVN R stated Resident #1 had an odor from refusing to shower, but he did not have a distinct odor that wound come from an infected wound that she could recall on 12/17/23. LVN R stated Resident #1 would always refuse his showers. LVN R stated Resident #1 was friendly with her but would even refuse for her to shower him. LVN R stated Resident #1 was mostly independent and could dress himself, so the chance for CNAs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675272 If continuation sheet Page 4 of 15 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 01/17/2024 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few to observe skin issues was limited, especially with Resident #1 not being able to communicate with them. LVN R stated the chance for wounds or new skin issues to be found would be during the weekly skin assessments done by the nurses. LVN R stated any new skin issues found on a resident would have to be assessed by the nurse and reported to the MD, DON, and RP immediately. In an interview on 01/17/24 at 3:28 PM, the Administrator stated to ensure that staff were conducting proper skin assessments and reporting all skin issues/change of condition, the DON and ADONs would continue monitoring all skin assessments and the monitoring and findings would be discussed with the team every morning during standup meeting for him to ensure that it was being done. The Administrator stated ongoing education would also continue with all staff and disciplinary actions would be taken for any staff not following protocols and processes put in place. The Administrator stated processes put in place regarding the facility's failure was addressed at the QAPI meeting held on 01/17/24. Record review of Resident #1's shower sheets, dated 12/5/23, 12/14/23, and 12/16/23, reflected the resident refused all showers. There was no documentation of skin issues on any of the shower sheets reviewed. No additional shower sheets could be provided. Record review of Resident #1's 24-hour reports, from 12/14/23-12/18/23, reflected there was no documentation of new skin issues or change of condition until 12/18/23 when LVN C reported the resident was sent out to the hospital for left great toe and right second toe being gangrene like. Record review of skin assessments dated 12/19/23-12/23/23, reflected a skin sweep of all residents in the facility with no findings. Record review of LVN C's personnel file reflected she was terminated on 12/19/23 for failure to notify the RP and physician to request an order for treatment when a new wound was documented on an assessment. The noncompliance was identified as PNC. The IJ began on 12/11/23 and ended on 12/18/23. The facility had corrected the noncompliance before the survey began. The facility took the following actions to correct the non-compliance prior to the survey: Interviews were conducted with CNA E (1st shift), Nurse Aide I (1st shift), LVN F (2nd shift), CNA G (2nd shift), and LVN H (2nd shift), LVN J (3rd shift), CNA K (3rd shift), CNA L (2nd shift), CNA M (2nd shift), CNA N (2nd shift), LVN O (2nd shift), LVN P (1st shift), LVN R (3rd shift) . All licensed staff were able to provide competency regarding in-service over policy on change of condition and when to communicate acute changes in residents' status to MD, DON, and responsible party. All licensed staff were able to state that all residents received skin assessments at least weekly, and more frequently for residents with existing skin issues. They were able to state that any new skin issues or worsening of existing skin issues should be assessed and immediately reported to the DON, MD, and RP, and any new orders followed. All CNAs were able to provide competency regarding in-service over change in condition, skin assessments during ADL care, and when to report changes in condition to the nurse. All CNAs were able to state that opportunities to assess residents' skin was during ADL care such as showers or incontinent care and when repositioning a resident. They were able to state that any change in condition or observation of skin issues should be immediately reported to the charge nurse. All CNAs were also able to state that if the issue was not addressed, they would report it to the DON. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675272 If continuation sheet Page 5 of 15 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 01/17/2024 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Interview and record review of Residents #2, #3, #4, #5, #6, and #7, who all received wound care, revealed there were no changes in condition and all residents had interventions in place to help prevent complications from wounds. Interview with Resident #2's RP revealed the residents wounds were healing and her legs were getting stronger. Interview with Resident #3 revealed he was satisfied with the wound care he was receiving, and the resident denied being in pain. Interview with Resident #4 stated he received wound care as ordered and had no concerns. Residents Affected - Few Interview with Resident #5's RP revealed he had no concerns with the wound care the resident was receiving and that he was notified when there was a change in condition. Interview with Resident #6 revealed no concerns with the wound care she was receiving. Interview with Resident #7 revealed the wound care nurse was great and he had no concerns. In an observation and record review on 01/17/24 of Resident #2, the resident was observed to have an open wound to her right lower leg with and a scab on a resolved wound to left shin. Record review of Resident #2's skin assessment, dated 01/17/24, reflected Resident #2 had one wound to her right lower leg. Record review of Resident #2's orders reflected an active order for daily wound care to right lower leg until resolved. Record review of Resident #2's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #3, the resident was observed to have an open wound to his left ankle and dark discoloration to lower left leg from poor circulation. Record review of Resident #3's skin assessment, dated 01/17/24, reflected he had one wound to his left medial (inner) ankle. Record review of Resident #3's orders reflected an active order to wash and dry his left leg twice daily, and an active order to provide wound care to left inner ankle every Wednesday. Record review of Resident #3's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #4, the resident was observed to have an open wound to his left heel. Resident #4 was wearing cushioned heel protectors. Record review of Resident #4's skin assessment, dated 01/17/24, reflected he had one wound to his left heel. Record review of Resident #4's orders reflected an active order for daily wound care to left heel. Record review of Resident #4's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #5, the resident was observed to have an open wound to her left heel and a resolved wound to the back of her neck. Investigator was unable to observe the wound on Resident #5's coccyx. Resident #5 was observed wearing a cushioned heel protector on left heel. Record review of Resident #5's skin assessment, dated 01/17/24, reflected she had a wound to her left heel and coccyx, and a resolved wound on neck. Record review of Resident #5's orders reflected an active order for daily wound care and heel protector to left heel, daily wound care to coccyx, and daily wound care to back of neck until resolved. Record review of Resident #5's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #6, the resident was observed to have open wounds to her left heel and left Achilles. Investigator was unable to observe Resident #5's sacrum. Record review of Resident #6's skin assessment, dated 01/17/24, reflected Resident #6 had a wound to her left heel, left Achilles, and a resolved wound to her sacrum. Record review of Resident #6's orders reflected an active order for daily wound care to left heel and left Achilles. Record review of Resident #6's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #7, the resident was observed to have a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675272 If continuation sheet Page 6 of 15 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 01/17/2024 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few surgical wound to his left below-knee amputation. Record review of Resident #7's skin assessment, dated 01/17/24, reflected he had a surgical wound to his left below-knee amputation medial (inner) and left below-knee amputation lateral (side of). Record review of Resident #7's orders reflected an active order for daily wound care to the resident's left below-knee amputation. Record review of Resident #7's TAR reflected wound care was being administered as ordered. Record review of Resident #7's nursing notes, dated 01/09/24, reflected the resident had a change of condition of the wound to his left below-knee amputation that was indicative of an infection. The MD was notified on 01/09/24 and new orders for antibiotics and an appointment for a debridement procedure was scheduled for 01/11/24. Further review of the nursing notes reflected the debridement procedure was completed on 01/11/24. In an interview on 01/17/24 at 1:00 PM, the LVN Q stated Resident #7 was the only resident in the facility who had a change of condition of wounds. She stated he was the MD was notified and Resident #7 was ordered to have a debridement procedure that was done on 01/11/24. Record review of in-service titled Change of condition/Abuse & Neglect, dated 12/20/23, reflected all staff were educated by the DON on monitoring skin/wounds, notifying the nurse of any changes of condition with residents, incontinent care, turning/repositioning, and charge nurses addressing change in condition as soon as possible, which included when to notify MD, RP of new orders, filling out incident reports, obtaining new orders, documentation and notifying the DON . Record review of the facility's policy titled Significant Change in Condition, revised 05/2007, reflected in part the following: Policy: It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical, mental, and psychosocial wellbeing in accordance with the interdisciplinary comprehensive assessment and plan of care. Procedures: 1. If at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to): . -Change in mental status -Any sign or symptom of infection . -Change in medical condition . 2. The Nurse will perform and document an assessment of the resident and identify need for additional interventions . 3. The resident will be placed on the 24-hour report and nursing will provide no less than three days of observation, documentation, and response to any interventions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675272 If continuation sheet Page 7 of 15 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 01/17/2024 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 0580 Level of Harm - Immediate jeopardy to resident health or safety 4. The nurse will communicate the change to other departments as appropriate and updated communications will be available during morning report. 5. There will be certain circumstances where immediate attention will be warranted, and nursing will be responsible for notifying the appropriate department for evaluation. The nurse shall use his/her clinical judgement and shall contact the physician based on the urgency of the situation Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675272 If continuation sheet Page 8 of 15 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 01/17/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure appropriate treatment and care was provided in accordance with professional standards, comprehensive person-centered care plan and resident choices for 1 of 5 residents (Resident #1) reviewed for quality of care. Residents Affected - Few -The facility failed to notify the physician and provide interventions to monitor and treat Resident #1 when LVN C observed and documented a new wound on his left toe. Resident #1 was high risk for infection due to comorbidities. The noncompliance was identified as PNC. The IJ began on 12/11/23 and ended on 12/18/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not having their physician notified concerning their medical needs which would cause a delay in treatment and a decline in health. Findings include: Record review of Resident #1's face sheet, dated 12/28/23, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included: type II diabetes (inability to regulate blood glucose), muscle weakness, acute osteomyelitis of left ankle and foot (inflammation of bone caused by infection), peripheral vascular disease (circulation disorder) and dementia (loss of memory and thinking). Record review of Resident #1's quarterly MDS assessment, dated 11/20/23, reflected his BIMS score was 08, which indicated moderate cognitive impairment. Record review of Resident #1's care plan, revised 9/13/23, reflected he had an ADL self-care deficit related to dementia, deconditioning, debility and left heel ulcer, with interventions which included staff providing physical assistance with daily self-care as needed. Further review reflected Resident #1 had a diabetic ulcer unstageable to the left heel and was at risk for further skin breakdown due to immobility and diabetes. Interventions included administering treatments as ordered and monitoring for effectiveness, assess/record/monitor wound healing, report improvements and declines to MD, encourage to turn and reposition, and follow facility policies/protocols for the prevention/treatment of skin breakdown. Record review of Resident #1's orders, dated 12/28/23, reflected an order to consult with MD for wound care. There were no active orders for wound care. Record review of Resident #1's weekly skin assessment, dated 12/7/23, reflected he had multiple wounds to right leg, and an old wound to left heel. Record review of Resident #1's weekly skin assessment, dated 12/14/23, reflected he had multiple wounds to right leg, left toe and an old wound to left heel. Record review of Resident #1's progress notes reflected there was no further documentation about notification to the MD regarding the new wound found on Resident #1's left toe according to his weekly skin assessment on 12/14/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675272 If continuation sheet Page 9 of 15 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 01/17/2024 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of in-service titled Weekly skin/ulcer assessment, dated 12/14/23, reflected all nurses were educated by the DON on weekly skin/ulcer assessments and notifying the RP and DON on changes. Record review of Resident #1's hospital records, dated12/28/23, reflected the resident was admitted to the hospital due to gangrene of his bilateral toes and lethargy. Resident #1 was diagnosed with osteomyelitis (inflammation of bone caused by infection) of right 3rd and 2nd toes, left great toes infection, chronic left heel ulcer, chronic anemia, severe tibia artery disease (circulatory disorder), and possible chronic kidney disease. Resident #1 had his left leg amputated below the knee on 12/21/2023 and his right leg was amputated below the knee on 12/26/23. Observation on 12/28/23 at 9:45 AM of Resident #1 at a local hospital, revealed he was lying in bed recovering from having a double below-knee amputation. Resident #1 was unable to be interviewed due to language barrier. In an interview on 12/28/23 at 9:46 AM, Resident #1's RP stated Resident #1 used a wheelchair for mobility; however, he was able to transfer independently and could do most ADLs independently. The RP stated Resident #1 was having a hard time adjusting to his limited abilities after having both legs amputated. The RP stated Resident #1 was active, able to communicate, and alert; however, when family visited him at the nursing facility on 12/28/23, he was disoriented, non-communicative, and did not recognize anyone. The RP stated it was then he noticed the toes on both of Resident #1's feet had turned black and once they complained to the nursing staff, Resident #1 was transported to the local hospital. The RP stated the nursing facility had not reported any changes in Resident #1's condition to him. In an interview on 12/28/23 at 10:28 AM at the local hospital, MD A stated he was the attending MD for Resident #1. MD A stated Resident #1 was admitted to the local hospital in 02/2023 due to wound infections with interventions which included debridement and antibiotic treatment. MD A stated Resident #1's recent amputation of both legs was due to infection and gangrene of multiple toes. MD A stated due to Resident #1's history he could not determine Resident #1's current condition was due to neglect by the facility without knowing information about treatment he was receiving at the facility; however, MD A stated Resident #1's age and diagnoses could have caused the infection to worsen rapidly, within less than a week without treatment. In an interview on 12/28/23 at 12:07 PM, LVN D stated she worked at the facility for 2 months. She stated she usually only worked the weekends but started working during the week about two weeks ago, while the facility's full-time wound care nurse was out. She stated she did wound care on Resident #1's left shin, and her last time providing care to him was a month ago because the wound was resolved. She stated she did not do wound care on Resident #1's feet because he did not have wounds on his feet at the time. She stated she knew because it was protocol to assess the feet when doing wound care on his legs. LVN D also stated she would check the orders and treatment assessment records to check for other treatments the resident needed, and he was not receiving any other wound care. In an interview on 12/28/23 at 12:48 PM, the DON stated she worked at the facility for about 3 weeks. She stated LVN C documented on 12/14/23 on Resident #1's weekly skin assessment he had a wound on his left toe that was not there the week prior. The DON stated LVN C informed her she did not notify the MD or report it to anyone because she thought the wound was already being treated. The DON stated her expectation was for the nurses to document any changes to the residents, check the orders for treatment and notify herself, the MD, and RP. The DON stated there were a lot of residents in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675272 If continuation sheet Page 10 of 15 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 01/17/2024 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few facility with wounds, so she had already provided an in-service on skin assessments and notification to all nurses on 12/14/23 as a precaution and prior to being aware that Resident #1 had a new wound. The DON stated LVN C received the training and still failed to notify anyone of Resident #1's new wound. The DON stated LVN C was terminated for failing to follow the facility's policy. In an interview on 12/28/23 at 1:37 PM, CNA E stated he worked at the facility for four months. He stated he worked with Resident #1 and the resident often refused showers and other care. CNA E stated about a week prior to 12/18/23, when Resident #1 was transferred to the hospital, he noticed Resident #1 was not eating and had severe diarrhea. CNA E also stated Resident #1 had a bad odor that smelled like it was coming from a wound. CNA E stated he reported this to the charge nurse, who was LVN C, and she stated she would notify the MD. CNA E stated he did not know if it was reported to the MD. In an interview on 12/28/23 at 2:25 PM, MD B stated she was one of the attending MDs at the nursing facility. She stated she typically saw Resident #1 once a month unless there was an issue. MD B stated Resident #1 admitted to the facility in 02/2023 with an infection in his foot after being treated at a local hospital. MD B stated it was recommended at that time Resident #1 have an amputation due to being high risk for infections, but his family declined, and Resident #1 was treated with IV antibiotics. MD B stated Resident #1 was also seeing a wound care specialist outside of the facility and his wounds had healed. She stated he would have intermittent wounds on his shins/legs from bumping them, but overall, he healed to her knowledge. MD B stated Resident #1 did not have any active orders for wound care, but she would have given one had she been notified that it was needed, especially due to Resident #1's history and comorbidities. MD B stated it was her expectation for the nurses to notify of any changes to her, and they were usually good about doing so. She stated she was not in front of the charts, but she could not recall being made aware of a new wound on Resident #1's left toe prior to him going to the hospital on [DATE]. She stated her first-time hearing of any issues for Resident #1 was on the day he was sent to the hospital. In a further interview on 12/28/23 at 5:45 PM, the DON stated the risk of not notifying the MD of a change in condition such as a wound could be it leading to a severe situation like sepsis and potentially death. In an interview on 01/17/24 at 10:48 PM, the DON stated since the facility's failure, processes were put in place to ensure it did not happen again. The DON stated a skin sweep of all residents in the facility was started on 12/19/23, with no change in condition or major skin issues found. She stated all CNAs were in-serviced on 12/20/23 on conducting skin assessments during ADL care and reporting any skin issues or change of condition to the charge nurses. The DON stated further education with CNAs would include reminding them to also report concerns or change of condition to management, including herself, the ADONs, or the Administrator. The DON stated all CNAs were informed to document any skin issues found during showers on the resident's shower sheets and to also report everything to the nurse no matter when it was found. The DON stated all nurses were in-serviced on 12/20/23 on addressing change of condition immediately and reporting to the MD, DON, and RPs. The DON stated all staff were also in-serviced on 12/20/23 on reporting abuse and neglect. The DON stated she and the ADONs were conducting daily monitoring of skin assessments completed by the nurses to screen for new skin issues/change of condition and to monitor the condition of existing skin issues. The DON stated there would also be continuous education and reminders to all staff on the importance of skin assessments and immediately reporting any change of condition. The DON stated all CNAs and nurses were given skin assessment skills checkoffs to ensure their understanding on how to conduct them. The DON stated all nurses were expected to know how to assess all shades of skin for discoloration and wounds (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675272 If continuation sheet Page 11 of 15 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 01/17/2024 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 0684 based on nursing skills obtain in nursing school. Level of Harm - Immediate jeopardy to resident health or safety In an interview on 01/17/24 at 11:12 PM, LVN Q stated she was the full-time wound care nurse at the facility. She stated she worked with Resident #1 and last provided wound care to him on 11/7/23 when the wound on his right shin was resolved. LVN Q stated all of Resident #1's wounds had resolved and there were no new orders for wound care besides a standing order to consult with the MD for wound care of any new wounds. LVN Q stated she the nurses and CNAs had a good rapport with her and would usually inform her of new wounds and skin issues found on the residents. She stated the CNAs knew to inform the charge nurses of new wounds or any change of condition of the residents, but if they saw her in the hallways, they would inform her also. LVN Q stated she had not been informed that Resident #1 had any new wounds or a change of condition since 11/7/23 after all his wounds were resolved. LNV Q stated Resident #1 had dementia and was Spanish speaking only, so he would often refuse ADL care and not interact with staff due to confusion and language barriers. LVN Q stated she was able to communicate with him in Spanish so he would comply with her more; however, she was had not worked with him since 11/7/23. She stated she was also on vacation for two weeks starting on 12/15/23, which was during the time LVN C found the new wounds. LVN Q stated Resident #1 had already discharged from the facility when she returned to work. LVN Q stated she was never made aware of the new wounds to Resident #1's toes. She stated she also was not aware of multiple wounds on his right leg. LVN Q stated the only wound to Resident #1's right leg that she was aware of was the one she was treating on his right shin that was resolved on 11/7/23. LVN Q stated Resident #1 often had superficial scratches and scabs from bumping his leg on the wheelchair, but he did not have any active orders for wound care. Residents Affected - Few In an interview on 01/17/24 at 12:46 PM, LVN R stated she worked PRN weekends at the facility and worked with Resident #1 on 12/17/23, the day before he was transferred to a local hospital. LVN R stated Resident #1 was acting his normal self and did not display any signs of pain or discomfort. LVN R stated the CNA did not report any change of condition of Resident #1 to her. She stated Resident #1 did not have diarrhea or a change in appetite on 12/17/23 or anything that needed to be reported to the MD. LVN R stated she was not aware of any new wounds that Resident #1 had. She stated she remembered an old wound that Resident #1 had on his left ankle or foot that had been resolved, but no new wounds. LVN R stated Resident #1 had an odor from refusing to shower, but he did not have a distinct odor that wound come from an infected wound that she could recall on 12/17/23. LVN R stated Resident #1 would always refuse his showers. LVN R stated Resident #1 was friendly with her but would even refuse for her to shower him. LVN R stated Resident #1 was mostly independent and could dress himself, so the chance for CNAs to observe skin issues was limited, especially with Resident #1 not being able to communicate with them. LVN R stated the chance for wounds or new skin issues to be found would be during the weekly skin assessments done by the nurses. LVN R stated any new skin issues found on a resident would have to be assessed by the nurse and reported to the MD, DON, and RP immediately. In an interview on 01/17/24 at 3:28 PM, the Administrator stated to ensure that staff were conducting proper skin assessments and reporting all skin issues/change of condition, the DON and ADONs would continue monitoring all skin assessments and the monitoring and findings would be discussed with the team every morning during standup meeting for him to ensure that it was being done. The Administrator stated ongoing education would also continue with all staff and disciplinary actions would be taken for any staff not following protocols and processes put in place. The Administrator stated processes put in place regarding the facility's failure was addressed at the QAPI meeting held on 01/17/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675272 If continuation sheet Page 12 of 15 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 01/17/2024 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of Resident #1's shower sheets, dated 12/5/23, 12/14/23, and 12/16/23, reflected the resident refused all showers. There was no documentation of skin issues on any of the shower sheets reviewed. No additional shower sheets could be provided. Record review of Resident #1's 24-hour reports, from 12/14/23-12/18/23, reflected there was no documentation of new skin issues or change of condition until 12/18/23 when LVN C reported the resident was sent out to the hospital for left great toe and right second toe being gangrene like. Record review of skin assessments dated 12/19/23-12/23/23, reflected a skin sweep of all residents in the facility with no findings. Record review of LVN C's personnel file reflected she was terminated on 12/19/23 for failure to notify the RP and physician to request an order for treatment when a new wound was documented on an assessment. The noncompliance was identified as PNC. The IJ began on 12/11/23 and ended on 12/18/23. The facility had corrected the noncompliance before the survey began. The facility took the following actions to correct the non-compliance prior to the survey: Interviews were conducted with CNA E (1st shift), Nurse Aide I (1st shift), LVN F (2nd shift), CNA G (2nd shift), and LVN H (2nd shift), LVN J (3rd shift), CNA K (3rd shift), CNA L (2nd shift), CNA M (2nd shift), CNA N (2nd shift), LVN O (2nd shift), LVN P (1st shift), LVN R (3rd shift) . All licensed staff were able to provide competency regarding in-service over policy on change of condition and when to communicate acute changes in residents' status to MD, DON, and responsible party. All licensed staff were able to state that all residents received skin assessments at least weekly, and more frequently for residents with existing skin issues. They were able to state that any new skin issues or worsening of existing skin issues should be assessed and immediately reported to the DON, MD, and RP, and any new orders followed. All CNAs were able to provide competency regarding in-service over change in condition, skin assessments during ADL care, and when to report changes in condition to the nurse. All CNAs were able to state that opportunities to assess residents' skin was during ADL care such as showers or incontinent care and when repositioning a resident. They were able to state that any change in condition or observation of skin issues should be immediately reported to the charge nurse. All CNAs were also able to state that if the issue was not addressed, they would report it to the DON. Interview and record review of Residents #2, #3, #4, #5, #6, and #7, who all received wound care, revealed there were no changes in condition and all residents had interventions in place to help prevent complications from wounds. Interview with Resident #2's RP revealed the residents wounds were healing and her legs were getting stronger. Interview with Resident #3 revealed he was satisfied with the wound care he was receiving, and the resident denied being in pain. Interview with Resident #4 stated he received wound care as ordered and had no concerns. Interview with Resident #5's RP revealed he had no concerns with the wound care the resident was receiving and that he was notified when there was a change in condition. Interview with Resident #6 revealed no concerns with the wound care she was receiving. Interview with Resident #7 revealed the wound care nurse was great and he had no concerns. In an observation and record review on 01/17/24 of Resident #2, the resident was observed to have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675272 If continuation sheet Page 13 of 15 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 01/17/2024 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few an open wound to her right lower leg with and a scab on a resolved wound to left shin. Record review of Resident #2's skin assessment, dated 01/17/24, reflected Resident #2 had one wound to her right lower leg. Record review of Resident #2's orders reflected an active order for daily wound care to right lower leg until resolved. Record review of Resident #2's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #3, the resident was observed to have an open wound to his left ankle and dark discoloration to lower left leg from poor circulation. Record review of Resident #3's skin assessment, dated 01/17/24, reflected he had one wound to his left medial (inner) ankle. Record review of Resident #3's orders reflected an active order to wash and dry his left leg twice daily, and an active order to provide wound care to left inner ankle every Wednesday. Record review of Resident #3's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #4, the resident was observed to have an open wound to his left heel. Resident #4 was wearing cushioned heel protectors. Record review of Resident #4's skin assessment, dated 01/17/24, reflected he had one wound to his left heel. Record review of Resident #4's orders reflected an active order for daily wound care to left heel. Record review of Resident #4's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #5, the resident was observed to have an open wound to her left heel and a resolved wound to the back of her neck. Investigator was unable to observe the wound on Resident #5's coccyx. Resident #5 was observed wearing a cushioned heel protector on left heel. Record review of Resident #5's skin assessment, dated 01/17/24, reflected she had a wound to her left heel and coccyx, and a resolved wound on neck. Record review of Resident #5's orders reflected an active order for daily wound care and heel protector to left heel, daily wound care to coccyx, and daily wound care to back of neck until resolved. Record review of Resident #5's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #6, the resident was observed to have open wounds to her left heel and left Achilles. Investigator was unable to observe Resident #5's sacrum. Record review of Resident #6's skin assessment, dated 01/17/24, reflected Resident #6 had a wound to her left heel, left Achilles, and a resolved wound to her sacrum. Record review of Resident #6's orders reflected an active order for daily wound care to left heel and left Achilles. Record review of Resident #6's TAR reflected wound care was being administered as ordered. In an observation and record review on 01/17/24 of Resident #7, the resident was observed to have a surgical wound to his left below-knee amputation. Record review of Resident #7's skin assessment, dated 01/17/24, reflected he had a surgical wound to his left below-knee amputation medial (inner) and left below-knee amputation lateral (side of). Record review of Resident #7's orders reflected an active order for daily wound care to the resident's left below-knee amputation. Record review of Resident #7's TAR reflected wound care was being administered as ordered. Record review of Resident #7's nursing notes, dated 01/09/24, reflected the resident had a change of condition of the wound to his left below-knee amputation that was indicative of an infection. The MD was notified on 01/09/24 and new orders for antibiotics and an appointment for a debridement procedure was scheduled for 01/11/24. Further review of the nursing notes reflected the debridement procedure was completed on 01/11/24. In an interview on 01/17/24 at 1:00 PM, the LVN Q stated Resident #7 was the only resident in the facility who had a change of condition of wounds. She stated he was the MD was notified and Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675272 If continuation sheet Page 14 of 15 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 01/17/2024 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 0684 #7 was ordered to have a debridement procedure that was done on 01/11/24. Level of Harm - Immediate jeopardy to resident health or safety Record review of in-service titled Change of condition/Abuse & Neglect, dated 12/20/23, reflected all staff were educated by the DON on monitoring skin/wounds, notifying the nurse of any changes of condition with residents, incontinent care, turning/repositioning, and charge nurses addressing change in condition as soon as possible, which included when to notify MD, RP of new orders, filling out incident reports, obtaining new orders, documentation and notifying the DON . Residents Affected - Few Record review of the facility's policy titled Significant Change in Condition, revised 05/2007, reflected in part the following: Policy: It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical, mental, and psychosocial wellbeing in accordance with the interdisciplinary comprehensive assessment and plan of care. Procedures: 1. If at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to): . -Change in mental status -Any sign or symptom of infection . -Change in medical condition . 2. The Nurse will perform and document an assessment of the resident and identify need for additional interventions . 3. The resident will be placed on the 24-hour report and nursing will provide no less than three days of observation, documentation, and response to any interventions 4. The nurse will communicate the change to other departments as appropriate and updated communications will be available during morning report. 5. There will be certain circumstances where immediate attention will be warranted, and nursing will be responsible for notifying the appropriate department for evaluation. The nurse shall use his/her clinical judgement and shall contact the physician based on the urgency of the situation FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675272 If continuation sheet Page 15 of 15