Health inspection·May 11, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of DON progress note dated 5/1/23 revealed that the DON educated Resident #25 and RP concerning failed swallow study emphasizing that it is unsafe for Resident #25 to consume regular textures after RP had fast food delivered to Resident #25. Per note, the RP verbalized that she would take risk of resident having whatever she wants to eat. Per note, RP stated that she was willing to sign a form to state that she and Resident #25 assume the risk of the resident eating what she wants. Per note, the DON educated the RP that the facility does not have a form/waiver to address that concern. Record review of the NP Progress dated 5/2/23 revealed that Resident #25 reported to NP that she was being provided a pureed diet and did not want it. NP note stated that Resident #25 is non-compliant with recommended diet and is not willing to be. NP documented that she explained to Resident #25 that the risk of a regular diet overweighs the benefit. Resident #25 confirmed understanding but still wishes to be on a regular diet. Record review of Resident #25's meal ticket dated 5/11/23 revealed that resident has an active order for and continues to receive Pureed diet. Record review of Resident Rights Under Federal Law: Attachment F (revised 2/22/22) revealed the following: 1. The Resident has a right to a dignified existence, self-determination . 5. The Resident has the right to refuse treatment . 9. The Resident has a right to participate in planning of his or her care and treatment or changes in care and treatment unless adjudged incompetent or otherwise . Observation on 5/9/23 at 12:30pm revealed that there was no tray in the resident's room during lunch time, only a bottle of Vanilla Ensure Enlive . In an interview on 5/9/23 at 12:30pm, Resident #25 stated that she supplements her diet with Ensure because she will not eat the pureed foods that she is being provided by the facility. Resident #25 said that she had a swallow test about two weeks ago and was ordered a pureed diet which she refuses to eat unless it is a food that's soft in its normal form (i.e. mashed potatoes, pudding). She said that she has expressed to doctor (NP), the nurse manager (DON), and anyone who will listen that she refuses to eat the pureed diet and would even sign something to say that she assumes the risks. She stated that the facility has made no accommodation for her in the 2 weeks she has been admitted and her family brings food and sometimes has food delivered that she can eat. Resident #25 stated that the situation is upsetting and that she would rather starve than eat the pureed meals provided to her . In an interview on 5/10/23 at 9:50am, the Administrator and DON both agreed that the resident has the right to refuse the pureed diet. The DON stated that the facility is honoring Resident #25's rights by not interfering with food brought from outside the facility. She said the facility only offers resident pureed items. The DON said that corporate does not offer a waiver for Resident #25 to decline pureed diet and accept risks of having a diet upgrade. The DON stated that Resident #25 failed a swallow test and for that reason, they must follow the physician order for the pureed diet. The DON stated that failure to honor the resident's rights could negatively impact the resident emotionally . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675274 If continuation sheet Page 2 of 8 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 675274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willis Nursing and Rehabilitation LP 3000 N Danville St Willis, TX 77378 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 5/10/23 at 10:15am, LVN C stated that all residents have the right to accept or refuse care. In an interview on 5/10/23 at 11am, Resident #25's NP stated that she is aware of Resident #25's request for a diet upgrade despite failed swallow test. She stated that she would be comfortable upgrading resident's diet if there was a waiver and plan in place that would allow for the resident and her RP to sign off stating they understand and accept the risks of upgrading resident's diet. She said that the problem is that the facility has no such waiver available. In an interview on 5/10/23 at 11:05am, the Social Worker acknowledged that the resident has the right to refuse a therapeutic diet even if prescribed for safety. She stated that she does not have a definite answer as to how the resident's rights will be honored as this issue has never come up at the facility in the 11 years she has been there. The SW acknowledged that not upholding resident's rights can have negative emotional impact because the facility is their home where their choices should be respected. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675274 If continuation sheet Page 3 of 8 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 675274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willis Nursing and Rehabilitation LP 3000 N Danville St Willis, TX 77378 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 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to honor the right of the resident to participate in the planning process and revision of the care plan to for 1 of 6 residents (Resident #25) reviewed for care plan. The facility failed to accommodate Resident #25's right to refuse her therapeutic diet and include accommodations in the resident's care plan. This failure could place residents at risk for not having their right to participate in the planning process of their individual person-centered plans of care. Findings included: Record review of Resident #25's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her relevant diagnoses included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), contracture of muscles (permanent tightening of muscles). Record review of MDS revealed Resident #25 with BIMS of 14 reflecting that Resident #25 had sufficient judgement, planning, organization to make her own decisions. Record review of Speech Language Therapy Evaluation and Plan of Care dated 4/26/23 revealed that Resident #25 was assessed for swallowing ability and was recommended a pureed diet (food blended to smooth, pudding-like consistency) with thin liquids due to with inability to fully clear mouth of leftover food after chewing and swallowing because of lingual weakness (weakness / difficulty moving the tongue). Record review of Resident #25's progress note dated 4/26/23 revealed that staff observed Resident #25 being fed onion rings and a hamburger by a relative. Per note, relative was told that Resident #25 would continue to receive a pureed diet until the diet order was changed by the physician. Record review of Resident #25's care plan nutritional status dated 5/1/23 revealed that Resident #25 was ordered a pureed diet and the goal was for resident to maintain weight. This section of the care also stated that the resident is noncompliant with MD prescribed diet (pureed) and that family and resident were educated of the risks of consuming otherwise (regular textures). Record review of DON progress note dated 5/1/23 revealed that the DON educated Resident #25 and RP concerning failed swallow study emphasizing that it was unsafe for Resident #25 to consume regular textures after RP had fast food delivered to Resident #25. Per note, the RP verbalized that she would take risk of resident having whatever she wanted to eat. Per note, RP stated that she was willing to sign a form to state that she and Resident #25 assumed risk of resident eating what she wanted. Per note, the DON educated RP that the facility did not have a form/waiver to address that concern. Record review of the NP Progress dated 5/2/23 revealed that Resident #25 reported to NP that she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675274 If continuation sheet Page 4 of 8 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 675274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willis Nursing and Rehabilitation LP 3000 N Danville St Willis, TX 77378 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 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was being provided a pureed diet and did not want it. NP note stated that Resident #25 was non-compliant with recommended diet and was not willing to be. NP documented that she explained to Resident #25 that the risk of a regular diet overweighed the benefit. Resident #25 confirmed understanding but still wished to be on a regular diet. Record review of Resident #25's meal ticket dated 5-11-23 revealed that resident had an active order for and continued to receive Puree diet. Record review of Resident Rights Under Federal Law: Attachment F (revised 2/22/22) revealed the following: 1. The Resident has a right to a dignified existence, self-determination . 5. The Resident has the right to refuse treatment . 9. The Resident has a right to participate in planning of his or her care and treatment or changes in care and treatment unless adjudged incompetent or otherwise . Observed on 5-9-23 at 12:30pm that there was no tray in the resident's room during lunch time, only a bottle of Vanilla Ensure Enlive. In an interview on 5-9-23 at 12:30pm, Resident #25 said that she had a swallow test about two weeks ago and was ordered a pureed diet which she refused to eat unless it was a food that's soft in its normal form (i.e. mashed potatoes, pudding). She said that she had expressed to doctor (NP), the nurse manager (DON), and anyone who would listen that she refused to eat the pureed diet and would even sign something to say that she assumed the risks. She stated that the facility has made no accommodation for her in the 2 weeks she had been admitted and her family brought food and Ensure and sometimes had food delivered that she can eat. Resident #25 said that she drinks the Ensure to supplement her diet when she refused the facility food. Resident #25 stated that the situation was upsetting and that she would rather starve than eat the pureed meals provided to her. In an interview on 5-10-23 at 9:50am, the Administrator and DON both agreed that the resident had the right to refuse the pureed diet. The DON stated that the facility was honoring Resident #25's rights by not interfering with food brought from outside the facility. She said the facility only offered the resident pureed items. The DON said that corporate did not offer a waiver for Resident #25 to decline pureed diet and accept risks of having a diet upgrade. The DON stated that resident failed a swallow test and for that reason, they must follow the physician order. The DON stated that failure to honor the resident's rights could negatively impact the resident emotionally. In an interview on 5-10-23 at 11am, Resident #25's NP stated that she was aware of Resident #25's request for a diet upgrade despite failed swallow test. She stated that she would be comfortable upgrading resident's diet if there was a waiver and plan in place that would allow for the resident and her RP to sign off stating they understand and accepted the risks of upgrading resident's diet. She said that the problem was that the facility had no such waiver available. The NP said that she had not yet discussed with the physician but would have that conversation with him. The NP said that that the team (Admin, DON, SW, NP) had been discussing among themselves how to handle the situation, but there was no documentation of a formal meeting having taken place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675274 If continuation sheet Page 5 of 8 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 675274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willis Nursing and Rehabilitation LP 3000 N Danville St Willis, TX 77378 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 0553 Level of Harm - Minimal harm or potential for actual harm In an interview on 5-10-23 at 11:05am, the social worker acknowledged that the resident has the right to refuse a therapeutic diet even if prescribed for safety. She stated that she did not have a definite answer as to how the resident's rights will be honored as this issue has never come up at the facility in the 11 years she had been there. The social worker said their next step would be to have a care plan meeting and include the resident, her daughter, and the ombudsman but, at that time, it had not been scheduled. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675274 If continuation sheet Page 6 of 8 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 675274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willis Nursing and Rehabilitation LP 3000 N Danville St Willis, TX 77378 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance to professional standards of practice and the resident's person-centered care plan for 1 of 12 residents (Resident #5), in that: Residents Affected - Few - Resident #5's laceration on foot failed to be reported to the Wound Care Nurse and treated. This failure could place residents at risk of not receiving adequate care in a timely manner. Findings included: Record review of Resident #5's face sheet revealed a [AGE] year old male who was admitted into the facility on [DATE] and was diagnosed with contracture of right lower leg muscle and quadriplegia, paralysis affecting all extremities below the neck. Record review of Resident #5's care plan, dated 02/11/2020, stated: Problem: [Resident #5] has current skin concerns as evidenced by: -irritation to face -tinea pedis -tinea unguium 04/10/2020. dry itching bilateral feet. - Apply Nystatin/Kenalog cream and OTC antifungal cream as ordered PRN. - Keep MD and RP informed of residents progress. - Keep MD and RP informed of residents progress. - Skin assessments as scheduled and PRN. Record review of Resident #5's physician's orders, dated 05/11/2023, revealed the resident had an active order to: Apply OTC antifungal cream to bilateral feet QD PRN dryness or itching since 4/10/2020 Apply compound nystatin cream/kenalog apply to face BID prn irritation since 02/25/2015 Record review of Resident #5's MDS, dated [DATE], revealed the resident had a BIMS score of 12 indicating resident's cognition was slightly impaired. Observations and interview with CNA G on 05/09/23 at 09:47 AM, revealed Resident #5 was observed with an approximately 2 X 0.5 inch scratch on the top of the resident's right foot that was pink in color. Resident #5 was observed rubbing his feet and legs against each other to scratch himself. CNA G said Resident #5 was known to have very dry skin and scratch himself and she uses a warm towel and cream to help with the itching, but his skin just soaks all the moisture up. CNA G said it was the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675274 If continuation sheet Page 7 of 8 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 675274 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willis Nursing and Rehabilitation LP 3000 N Danville St Willis, TX 77378 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 first time she had seen this scratch on his foot and that it looked fresh. Level of Harm - Minimal harm or potential for actual harm In an interview with Resident #5 on 05/09/23 at 12:23 PM, he stated his main concern was that his skin on his inner thigh and top of his foot felt very itchy. Residents Affected - Few In an interview with the Wound Care Nurse, on 05/11/2023 at 1:55PM, she stated she knew the resident has had complications with itchy skin and flare-ups for a while and had PRN creams to help with the itch but she was not recently notified about any new skin issues that Resident #5 had. She stated the nurse aides have to do skin assessment/shower sheet and report any new concern to her and the nurse aides have not been doing them or else it would have been reported to her. Record review of Resident #5's shower sheets revealed the last shower sheet documented was from 05/08/2023 with no noted skin issues on his feet. Observations and interview with LVN K on 05/11/2023 at 2:00PM, he stated he was not made aware of any new skin concerns for Resident #5 recently. Surveyor requested to observe Resident #5's skin while resident was dressed and lying in a Geri chair. Resident #5 was seen grimacing saying I don't want-repeatedly as LVN pulled the resident's sock off. The resident's skin appeared bright reddish pink and LVN K saw his skin on left foot and stated, that's definitely open. Resident #5 was then observed being taken back to his room by LVN K and the Wound Care Nurse for a skin assessment. Record review of Resident #5's skin assessment dated [DATE] at 2:57PM revealed resident was assessed to have a skin tear/laceration and was ordered new wound treatment. In an interview with CNA F on 05/11/23 at 02:23 PM, CNA F reported Resident #5 was given a bed bath this morning after being soiled and she forgot to write it on a shower sheet that he had a sore on his right foot, it was not bleeding but it was very open. She stated she put his personal Vaseline over it and put his socks on. She stated that was the first time she had seen the wound and she would usually call a nurse to notify them then and there, but she did not notify the nurse because it slipped her mind. She stated the risk of not reporting and addressing open wounds is possible infection. In an interview with the DON on 05/11/2023 at 2:37PM she stated CNA F should have reported the skin change to the charge nurse who would have followed up by looking at the resident's skin or sending wound care to assess and coordinate appropriate treatment with the doctor to ensure treatment is appropriate. She stated the risks of not having resident's skin concerns reported is that the resident's skin would remain not intact and could potentially get worse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675274 If continuation sheet Page 8 of 8