Health inspection·October 20, 2023

F 0689 Level of Harm - Actual harm Residents Affected - Few Record review of the hospital records dated [DATE] of Report of Operative Procedure from Hospital #2 revealed, Resident #1 presented to the hospital after sustaining a laceration of the back of the calf and a fracture to the thigh bone at the skilled nursing facility. Further review of hospital records revealed during knee replacement surgery, the resident experience respiratory complications requiring chest compression. The resident was transferred to ICU and passed away. In an interview on [DATE] at 9:30AM with the Administrator, she stated during a use of a mechanical lift, two nurses (LVN A and LVN B) were transferring Resident #1 on back into bed and the resident bumped her leg which caused a laceration. She stated Resident #1 was sent out to the hospital because she had a laceration. The Administrator stated Hospital #1 transferred Resident #1 to Hospital #2 and stated the reason of the 2nd transfer was unknown. She stated the first hospital did not inform the facility that the resident had a fracture, she stated she was informed of the fracture by the 2nd hospital. The Administrator denied that the resident had a fall during the transfer. The Administrator also denied that the fracture was caused by the resident hitting her leg during the transfer. The Administrator reported she believed the fracture could have occurred during the residents transfer to the hospital. In an interview on [DATE] at 10:50AM with LVN B, he stated he had worked at the facility since [DATE] and he worked from 6am-6pm. He stated he and LVN A was assisting Resident #1 with getting back into bed via mechanical lift because the resident was a 2 person assist. He stated the resident scrapped the back of her leg while getting into the bed. LVN B stated he saw the scrape and it looked as if the resident could have required stitches, so she was sent out to the hospital. He stated the resident never fell during the transfer. She stated she was in-serviced on mechanical lift after the incident occurred. In an interview on [DATE] at 11:22AM with LVN A, she stated she had been employed at the facility for 22 years. She stated she worked the 6am-6pm shift. LVN A stated Resident #1 had been up and wanted to lay back down. She stated the CNAs were at lunch so she and LVN B helped Resident #1 get back in bed. She stated Resident #1 was in a sling for the mechanical lift, and when she and LVN B went to lay her down the resident's lower leg bumped into the bed, and the resident sustained a cut. She stated Resident #1 was sent out to the hospital because of the cut on her leg. She stated the DON and Administrator was immediately notified. LVN A denied that the resident ever had a fall during the transfer. LVN A stated she was in-serviced on lifts. Observation on [DATE] at 1:53PM of CNA A and CNA B during Resident #2's Hoyer lift transfer into bed. CNA A was observed connecting the slings to the Hoyer lift and CNA B ensured the wheelchair was locked in place. CNA B was observed standing near the residents' feet and CNA A was observed standing near the residents head. CNA A controlled the lift controller. Resident #2 was transferred into bed and there were no concerns. In an interview on [DATE] at 2:23PM with the DON, she stated she had been employed at the facility for a few weeks. She stated she was not familiar with the incident that occurred with Resident #1 because she was not employed at the facility. She stated the expectations for mechanical lift were that it takes at least 2 people to assist the resident. She stated one person should be controlling the machine and the other person should be positioning the patient. She stated the sling should be positioned under the back and bottom. She stated the staff were in-service on lifts annually and if there was an incident, the in service were repeated. Telephone call on [DATE] at 3:02 PM to NP-No answer, voicemail was full so unable to leave a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675274 If continuation sheet Page 2 of 5 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 10/20/2023 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 0689 message. Level of Harm - Actual harm Telephone call on [DATE] at 3:04PM to Physician- phone went to voicemail, voicemail was left. Residents Affected - Few In an interview on [DATE] at 4:00PM with OT- She stated she did therapy with Resident #1 when she was at the facility for about 3 weeks until she went into the She stated the resident did need a lot of assistance due to being blind and she also required self-care skills with feeding. She stated Resident #1 had a spacer in her left knee which always kept her leg extended. She stated the resident had an elevated footrest to keep her foot to an extent. The resident had to be transferred towards her right leg and use the gait belt to keep it extended. The resident was non weight barring on that left leg. She stated the therapist used a gait belt to transfer the resident during therapy sessions and the staff members used a Mechanical Lift for transfers when the resident needed to be transferred. She stated the staff did not have to get any type of special training to transfer the resident since Mechanical lifts did not require the resident to have any weight on her legs during transfers. Telephone call on [DATE] at 10:02 AM to NP-No answer, voicemail was full so unable to leave a message. Record review of Resident #1's PT Evaluation and Plan of Treatment dated [DATE] revealed the residents weight bearing status was non weightbearing on her left lower extremity. Record review of Resident #2 face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Type 2 diabetes mellitus without complications, brain damage caused by lack of oxygen, muscle loss, contracture of muscle to the right lower leg, and contracture of muscle to the left lower leg. Record review of the Gait Belt Transfer Skills Checklist for LVN A dated on [DATE] read in part: .Comments: Education and training on 2-man Hoyer lift transfers as well . Record review of the Gait Belt Transfer Skills Checklist for LVN B dated on [DATE] read in part: .Comments: Education and training on 2-man Hoyer lift transfers as well . Record review of Hoyer Lift and Transfer training for all staff dated [DATE]. Record review of incident intake #433231 read in part: .Narrative of The Incident - Resident #1 was discharged to Hospital #1 on [DATE] after acquiring a laceration during a Hoyer transfer. On [DATE] the facility was contacted by the family of Resident #1 and informed that the resident expired on 6/25 due to a blood clot during a knee and femur surgery at Hospital #2 . Record review of the facilities Safe, Lifting and Movement of Residents policy dated [DATE] read in part: .In order to protect the safety and well-being of the staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation: 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents . 3.Staff will document resident transferring and lifting needs in the care plan .4. Staff responsible for direct care will be trained in the use of manual .and mechanical lifting devices. 5. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. 6. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents .Safe lifting and movement of residents is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675274 If continuation sheet Page 3 of 5 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 10/20/2023 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 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete part of an overall facility employee health and safety program, which: a. Involves employees in identifying problem areas and implementing workplace safety and injury prevention strategies; .d. Continually evaluates the effectiveness of workplace safety and injury-prevention strategies. It was determined these failures resulted in a deficient practice from [DATE] to [DATE]. facility took the following action to correct the non-compliance on [DATE]: Event ID: Facility ID: 675274 If continuation sheet Page 4 of 5 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 10/20/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interviews and record review the facility failed to ensure all drugs and biologicals were stored securely for one (Nurse Cart #6) of four medication carts reviewed for storage of medications. Nurse Cart #6 had a punctured protective seal on the back of a narcotic medication blister pill card. This failure could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and drug diversion. Findings included: Observation on 09/24/2023 at 12:20 PM revealed the narcotic storage of Lorazepam 0.5 mg tablets # one tablet had a torn protective seal. The blister contained one and a half small white tablets. This was the last dose in the pill card that had 30 blisters. In an interview on 09/24/2023 at 12:20 PM with LVN A stated she was not sure why the tear on the back of the Lorazepam pill card was there. LVN A stated she counted with the night nurse in the AM and did not notice the tear. LVN A stated if the Lorazepam was due again, she would see the tear and would waste (destroy and render unusable) it. LVN A stated she would waste the medication with another nurse. LVN A stated it would not be OK to ever tape over the tear. LVN A stated sometimes during popping out of a tablet, our fingers may puncture the back of the blister package. In an interview on 09/28/2023 at 1:50 PM, the Clinical Resource Nurse stated torn blister cards should not be in the medication cart. She stated the nursing staff should be looking at the back of the cards to make sure there are no holes. She stated the risk to the resident would be an infection control risk. She stated if the tablet should fall out, it could be a case of drug diversion. She stated if the tablet falls to the floor, hopefully it would not be picked up and taken by a resident as it could cause adverse reactions. Record review of facility's policy titled Storage of Medications, revised November 2020 revealed in part .Policy heading: The facility stores all drugs and biologicals in a safe, secure and orderly manner. Policy Interpretation and Implementation: 1. Drugs and biologicals used in the facility are stored in locked compartments and under proper temperature .2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received . 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner .6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes containing drugs and biologicals re locked when not in use . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675274 If continuation sheet Page 5 of 5