Health inspection·October 19, 2023

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further observation at 11:55 a.m. the Surveyor then knocks on the door and CNA A was trying to put Resident #1's pant up, the privacy curtain between Resident #5 and her roommate's bed was drawn but the one to the entrance door to the hallway was not drawn. At that point the Surveyor told her to pull the privacy curtain to the entrance door to the hallway. In an interview with CNA A on 10/18/2023 at 12:30 p.m. she said she usually does not pull the privacy curtain when she provides care to Resident #5 because her roommate was not usually in the room. She said she was taught to pull the privacy curtain when providing care to residents. She said Resident #5 roommate was in the room and she should have drawn the privacy curtain. She said she did not know what happened, because she usually pulls the privacy curtain when Resident #5 was in the room. She said she was in-service on providing privacy that means she should always pull the privacy curtain and closed the doors when providing care. She said she did not know why she did not do what she was trained to do. During an interview on 10/18/2023 at 12:55 pm., with the DON said that when staff were providing care to residents, they should always provide privacy, drawing the privacy curtains, closing the door, and talking to them to make them comfortable. She said they were in-serviced on privacy. She said she will just have to in-service them again. Record review of the facility's policy and procedure dated February 2021 title Dignity read in part . Policy Statement: Each resident shall be cared for in a matter that promotes and enhances his or her sense of well-being, level of satisfaction with life and feelings of self-worth and self-esteem. Employees should treat all residents with kindness, respect and dignity. Policy Interpretation and Implementation 11. Staff promotes, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Perineal Care Policy Statement: Perineal care is providing cleanliness and comfort to the resident, to prevent infection, skin irritation and to observe the resident skin condition. Steps in procedure: 1. Introduce self to resident and explain care that will be provided. Provide privacy i.e. pull curtain and close door. 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 10/19/2023 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 provide the necessary services to maintain personal hygiene for 1 of 5 residents (Resident #1) reviewed for activities of daily living. Residents Affected - Few -The NF failed to provide proper perineal/incontinent care for Resident #1. This failure placed resident at risk for UTI's (urinary tract infections), sepsis (presence of harmful bacteria in the blood), and unwanted hospitalization. Findings included: Resident #1 Record review of Resident #1's face sheet revealed a 62year old male admitted to the NF on 08/26/2023 with diagnoses that included the following: monoplegia (paralysis to one extremity or region of the body) upper limb following nontraumatic subarachnoid hemorrhage (bleeding on the brain) affecting left non-dominant side, dementia (impairment of memory and judgement) moderate, with other behavior disturbance, gastro-esophageal reflux disease (stomach acid or bile flows into the food pipe and irritates the lining) without esophagitis (inflammation that damages the tube running through the throat to the stomach), benign (growth that is not cancerous) prostatic hyperplasia (prostate enlargement that can cause urination difficulty) without lower urinary tract symptoms, dysphagia (difficulty swallowing), aphasia (loss of the ability to understand or express speech), and gastrostomy (surgical opening into the stomach from the abdominal wall). Record review of Resident #1's MDS dated [DATE] revealed that resident had a BIMS score of 3 indicating that resident cognition was severely impaired. Further review revealed that resident required assistance with activities of daily living due to total dependence with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. Further review revealed that resident was always incontinent of bowel and bladder. Record review of Resident #1's Care Plan dated 08/21/2023 revealed that resident was being care planned for incontinence of bowel and bladder with intervention that included to provide incontinent care after each in incontinent episode and to monitor skin and report any changes. Observation on 10/18/2023 at 12:55pm CNA B performing perineal care for Resident #1 with the assistance of LVN D. CNA B entered resident room and washed her hands with soap and water, placed on a set of gloves and began to remove resident brief that was stained with feces. CNA B positioned resident to his left side with the assistance of the LVN D and began to clean resident rectal area with disposable wipes one wipe at a time. CNA B placed soiled material inside of a plastic bag. When CNA B was done cleaning resident anus and buttocks, she then positioned resident on his back with the assistance of the LVN D and began to clean resident perineal area (skin between the scrotum and anus and bottom region of the pelvic). The CNA B did not change her gloves and wash her hands. The CNA B proceeded to clean resident groin that had feces on the disposable wipes. When CNA B was done cleaning the groin area, she then began to clean resident penis starting at the urethral meatus (opening from the inside to the outside) not cleaning downward and away from the urethral meatus instead, cleaned in a circular motion upward. When CNA B was done providing care, she then removed her gloves and washed her hands with soap and water. (continued on next page) 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 10/19/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Interview on 10/18/2023 at 1:10pm CNA B said she should have cleaned resident first starting in the front and moving to the back. CNA B said she should have started at the tip of resident penis retracting the foreskin of the penis and cleaning the penis by moving downward in a circular motion away from the urethral meatus. CNA B said these steps should have been taken to avoid infections like UTI's. CNA B said she became nervous and started making mistakes. Residents Affected - Few Interview on 10/18/2023 at 1:35pm the DON said when administering perineal/incontinent care for a male resident, the staff should be starting at the meatus cleaning down and away from the meatus to prevent introducing bacteria in the urinary tract that could cause UTI's. Record review of the NF Policy on Perineal Care revised 01/20/2023 revealed in part: .Perineal Care is providing cleanliness and comfort to the resident, to prevent infections, skin irritation, and to observe the residents skin condition .For male resident .clean perineal area starting with urethra and working outward .Retract foreskin of the uncircumcised male .Clean urethral area with a cleansing wipe using a circular motion .Continue to clean the perineal area including the penis, scrotum, inner thighs .Turn on his side .clean the anus, and buttocks . 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 10/19/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services to restore, if possible, oral skills and to prevent complication of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal pharyngeal ulcers for 1 of 5 residents (Resident #1) reviewed for quality of care. -CNA failed to inform the nurse to stop Resident #1's continuous gastrostomy feedings while providing incontinent care with resident head of bed flat. The failure placed resident at risk for aspiration, pneumonia, and unwanted hospitalization. Findings included: Record review of Resident #1's face sheet revealed a 62year old male admitted to the NF on 08/26/2023 with diagnoses that included the following: monoplegia (paralysis to one extremity or region of the body) upper limb following nontraumatic subarachnoid hemorrhage affecting left non-dominant side, dementia, moderate, with other behavior disturbance, gastro-esophageal reflux disease without esophagitis, benign prostatic hyperplasia without lower urinary tract symptoms, dysphagia, aphasia, and gastrostomy. Record review of Resident #1's MDS dated [DATE] revealed that resident had a BIMS score of 3 indicating that resident cognition was severely impaired. Record review of Resident #1's Care Plan dated 08/21/2023revealed that the NF was care planning resident for feeding tube an intervention that included to provide enteral (nutrition delivered using the stomach) feedings as ordered. Record review of Resident #1's Physician orders revealed the following orders dated 08/12/2023 enteral feeding (aspiration precaution) elevate HOB 30-45-degree, order dated 08/30/2023 for enteral free water give 200ml per tube q hrs., and an order dated 10/17/2023 revealed enteral formula Glucerna 1.5 to run at 55ml/hr. for 22 hours per day. Observation on 10/18/23 at 11:40am Resident #1 was resting on his left side in bed on an air mattress with head of bed flat. Resident was receiving continuous gastrostomy feedings Glucerna 1.5 (hung on 10/18/23 at 4:00am) infusing at 55ml/hr. Further observation was made of resident also receiving water flush 200ml every 4 hours. NA C was providing incontinent care for resident who had a bowel movement. Further observation was made of resident not appearing to be in any distress. Interview on 10/18/23 at 11:50am NA C said LVN D was aware that she was going to provide incontinent care for Resident #1. NA C said she had been working at the NF for 8 weeks and was not supposed to be working on the unit by herself. NA C said she was not a CNA because she was still in training. NA C said she did not know what she was supposed to do prior to providing incontinent care for a resident on continuous gastrostomy feedings. Interview on 10/18/23 at 11:55am LVN E said she was not the nurse taking care of Resident #1 and believed resident nurse may had been on break. When LVN E observed resident head of bed being flat (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 10/19/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with continuous feedings infusing, LVN E said resident head of bed should be elevated to 45 degrees to prevent resident from aspirating. LVN E elevated resident head of bed. Interview on 10/18/23 at 12:00pm LVN D said she had been working at the NF for a little over a year. LVN D said NA C never asked her to assist with incontinent care for Resident #1. LVN D said whenever incontinent care was being provided for a resident receiving continuous gastrostomy feedings, the feedings must be stopped to prevent resident from aspirating. LVN D said NA should have informed her what she was going to do so she could have placed the feeding on hold and disconnect tubing from resident. LVN D said she would have assisted NA C with incontinent care if she had asked. Further interview on 10/18/23 at 12:10pm NA C said she was in the TNA (Training Nurse Aide) Program and had completed her hours just needed to take her exam. NA C said she became frustrated when she said she was not supposed to be working at the NF by herself. NA C said Resident #1 had a new G-Tube (gastrostomy tube) because she had worked with Resident #1 in the past and he did not have one that she could remember. NA C said she had gone to LVN D for assistance and that LVN D did not respond to her when she had asked her what she was supposed to do because resident was receiving continuous gastrostomy feedings. NA C said LVN D did not answer because she was busy doing something else. NA C said she proceeded to care for Resident #1 because he was incontinent of stool and needed to be cleaned. Interview on 10/18/2023 at 12:22pm DON said she had been working at the NF for 1 month. The DON said the TNA (Training Nurse Aide) Program she believed the policy stated that another staff member must buddy up with the person in training until they became a CNA but would have to confirm with the Administrator. The DON said prior to a staff providing care for a resident (s) with a continuous feeding they should inform the nurse first so that the nurse could stop and disconnect the feedings. The DON said this was done to prevent the resident from aspirating. Further interview with the DON said the NF had 4 residents that were receiving continuous gastrostomy feedings. Interview on 10/18/23 at 1:25pm Administrator said the NF did not have a policy on their TNA Program but went by the state guidelines regarding training for nurse aide. The Administrator said there was nothing in the NATCEP (Nurse Aide Training and Competency Evaluation Program) that specified that NA C could not be alone when administering care for the residents. The Administrator said moving forward, she would ensure that NA C received more training in the areas of gastrostomy tubes. The Administrator said NA C had completed her competency skill check list regarding resident care. The Administrator said it was CNA B that checked NA C off in her competency skills. The Administrator said it was ultimately the DON that was responsible in ensuring that the nurse aides was able to perform each task on the competency check off list. The Administrator said the Corporate Regional Nurse also assisted with the nurse aide skills competency checkoff. The Administrator said the previous DON left the facility in July 2023 and after that, the NF had two interim DON in the month of August 2023. The Administrator said the NF new DON started working at the NF on 09/01/2023. Record review of Nurse Aide Skills Competency Checklist for NA C revealed that NA C had been checked off for nutrition and elimination regarding G-Tube (Gastrostomy Tube) on 08/02/2023. Record review of the NF Policy on Enteral Feedings-Safety Precautions revised May 2014 revealed in part: .Always elevate the head of bed at least 30-45 degree during tube feeding . 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 10/19/2023 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 0880 Provide and implement an infection prevention and control program. 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 maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection for 1 of 5 (Resident #1) reviewed for infection control. Residents Affected - Few -NA C failed to place soiled linen in bag during incontinent care, instead of placing the soiled linen on floor. This failure placed residents at risk for cross contamination, spread of infections, and decrease in quality of life. Findings included: Record review of Resident #1's face sheet revealed a 62year old male who was admitted to the NF on 08/26/2023 with diagnoses that included the following: monoplegia (paralysis to one extremity or region of the body) upper limb following nontraumatic subarachnoid hemorrhage affecting left non-dominant side, dementia, moderate, with other behavior disturbance, gastro-esophageal reflux disease without esophagitis, benign prostatic hyperplasia without lower urinary tract symptoms, dysphagia, aphasia, and gastrostomy. Record review of Resident #1's MDS dated [DATE] revealed that resident has a BIMS score of 3 indicating that resident cognition was severely impaired. Further review revealed that resident required assistance with activities of daily living due to total dependence with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. Further review revealed that resident was always incontinent of bowel and bladder. Record review of Resident #1's Care Plan dated 08/21/2023 revealed that resident was being care planned for incontinence of bowel and bladder with intervention that included to provide incontinent care after each in incontinent episode and to monitor skin and report any changes. Observation on 10/18/23 at 11:40am Resident #1 was resting on his left side in bed on an air mattress. Resident was receiving gastrostomy feeding via (by way of) pump. Further observation was made of NA C providing incontinent care for resident who had a bowel movement. There was soiled linen directly on floor not inside a bag. Interview on 10/18/23 at 11:50am NA C said the reason she placed the soiled linen on the floor was because the soiled linen barrel was right outside resident's door. NA C said she did not have a bag to place the soiled linen inside of. Further interview with NA C she said she should have bagged the soiled linen and placed it inside of soiled linen barrel to prevent the spread of infections. NA C said she did not know why she did that because she had been trained on infection control. Interview on 10/18/23 at 12:00pm LVN D said she was the nurse for Resident #1 and that soiled linen should be placed inside of plastic bag and transferred to soiled utility room for infection control purposes. Interview on 10/18/2023 at 12:22pm the DON said she had been working at the NF for 1 month. The DON said when the nursing staff provide incontinent care for a resident, the soiled barrel should be (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 10/19/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few outside the resident door so that the nursing staff could place the soiled linen inside of the barrel. The DON said if the barrel for soiled linen was not at the doorway, the staff had to bag the soiled linen and take to the soiled utility room. The DON said this was done to prevent the spread of infections. Record review of the NF Policy on Infection Prevention and Control Program revised October 2020 revealed in part: .An infection prevention and control program was established and maintained to provide a safe, sanitary comfortable environment and to help prevent the development and transmission of communicable disease and infections . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675274 If continuation sheet Page 8 of 8