Health inspection·August 21, 2025

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete then.Interview on 8/21/25 at 10:35AM, the DON stated Resident #34 was receiving oxygen d/t her O2 saturation rates would drop when she was non-compliant. When asked what the risks were to the resident if she did not receive oxygen as ordered, the DON stated the orders would have to be followed and that she would have to ask the MD. The DON stated she expected the nurses to check oxygen settings every shift at least once a day and follow physician orders.Interview on 8/21/25 at 10:40AM, LVN-A stated she was familiar with Resident #34. LVN-A stated Resident #34 had COPD and would get confused if not enough oxygen or too much oxygen was received. LVN-A stated all the nurses were responsible for checking accuracy of oxygen therapy. LVN-A stated during her first round of the day she would check oxygen settings and the level of water in the bottles.Record review of Resident #34's MAR/TAR revealed the oxygen concentrator filter was cleaned weekly on 08/17/25 between 6:00 PM and 6:00 AM. The oxygen humidification bottle was replaced or refilled as required every shift. (6:00AM-6:00PM, and 6:00PM 6:00AM).Record review of the facility's policy for oxygen concentrator, date implemented was 07/2025 read in part: The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators.2. Oxygen is administered under orders of the attending physician, except in the case of an emergency.4. a. the nurse shall verify physician's orders for the rate of flow and route of administration of oxygen (mask, nasal cannula, etc.). Event ID: Facility ID: 675274 If continuation sheet Page 2 of 4 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 08/21/2025 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled: Residents Affected - Few Number of residents cited: Based on observations, interviews, and record reviews the facility failed to maintain an effective pest control program so that it remains free of pests for one Resident's bathroom (Resident #19) out of 22 bathrooms and one hallway out of four hallways reviewed for pests.-The facility failed to ensure the building was free of cockroaches. A cockroach was found on the Surveyor's clothing while standing in a hallway during medication pass. A cockroach was observed in Resident #19's bathroom on two separate occasions.These failures could put residents at risk of, infection, allergies, skin irritation, unsanitary living conditions and decline in health and well-being.Findings include:Record review of Resident #19's face sheet dated 08/21/25 revealed a [AGE] year-old admitted to the facility on [DATE] and initially admitted on [DATE]. His diagnoses included a stroke, depression, fungal infection of the skin and nails, Hemiplegia (one sided paralysis or severe loss of strength on one side), contractures of the muscle and anxiety.Record review of Resident #19's quarterly MDS dated [DATE] revealed a BIMS score of 11 out of 15 indicating moderate cognitive impairment. Resident #19 was dependent on staff for almost all ADLs.Record review of Resident #6's face sheet dated 08/20/25 revealed a [AGE] year-old admitted to the facility on [DATE] and initially admitted on [DATE]. Her diagnoses included heart failure, COPD (chronic obstructive pulmonary disease) (a lung condition caused by damage to the airway), schizophrenia, muscle wasting, high blood pressure and depression. Resident #6 used a walker for mobility and independent with all ADLs.Record review of Resident #6s annual MDS dated [DATE] revealed a BIMS score of 12 out of 15 indicating moderate cognitive impairment.Observation and interview on 8/20/25 at 6:30AM, during med pass in the hallway, a small brown, long, thin, oval shaped cockroach was found on Surveyor's shirt. Initially itching began on the back of the neck, then pin prick sensation was felt on back of right shoulder. The cockroach crawled over the front of the chest and then onto the outside of shirt. Immediate itching and two small, raised bumps were on the skin on back of the shoulder. MA-C stated if she saw pests, including cockroaches she would write it in the workorder book at the nurse station and would also inform maintenance.Observation and interview on 08/20/25 at 11:58 AM a long, thin, brown crawling insect was found running out from behind the toilet in Resident #19's bathroom. The Regional Maintenance Consultant at the time of observation, when asked if he were aware of insects in the facility, he stated no, and that the pest control was here last week. When asked who checked for insects, he stated all the staff would report if they saw one. When asked how often the pest control company perform an inspection, he stated monthly and they were on-call. When asked how this affected the residents, he stated it would spread disease, be unsanitary, and there could be a possible infestation.In an interview on 08/20/25 at 3:00 PM, LVN-A was asked how would it affect residents if cockroaches were around, LVN-A stated it would not be clean or healthy and an infection control issue. LVN-A stated if she observed a cockroach, she would write a workorder for the maintenance to address. LVN-A stated we do live in Texas and there are roaches here.In an interview on 08/20/25 at 3:05 PM, The Regional Maintenance Consultant stated he did not see any cockroaches today, and only saw ants outdoors. The Regional Maintenance Consultant stated he heard about the Surveyor's report of the cockroach sighting, and he did some spraying. He stated that staff would document any sightings in the workorder book and let him know. The Regional Maintenance Consultant stated he called pest control today d/t the ants outside and that they would be at the facility 08/21/25.In an interview on 08/20/25 at 3:15 PM, the DON, when asked how cockroaches inside the building affect residents, she stated they were gross and scary. When asked if cockroaches carried disease, the DON stated yes. The DON stated maintenance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675274 If continuation sheet Page 3 of 4 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 08/21/2025 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete scheduled monthly Pest Services and they spray for pests.Observation and interview on 08/21/2025 at 12:33 PM in Resident #19's bathroom a small brown cockroach with wings visible crawled in the gap between the toilet and the floor, when the door was opened and the light turned on. Resident #19 stated he had seen the large yard cockroaches come into the building during heavy rain but had not seen any cockroaches recently. Resident #19 stated he did not like them being around and if they don't crawl all over him, he was ok with them. Resident #19 stated he did not use the bathroom as he cannot get out of bed. In an interview on 08/20/25 at 3:25 PM, Resident #6 resided in Hall 5, stated she had not seen any cockroaches recently but when she was in a different hall about a year and a half ago there was an awful cockroach problem. Resident #6 stated her roommate at the time would soil her brief often and thought maybe that was attracting the cockroaches. Resident #6 stated they were icky, and one got onto her face back then, she wanted to scream.Record review of the facility pest control logbook revealed roaches were sighted on, and addressed by pest control technicians: 12/26/24, addressed on 01/09/25 03/13/25, 03/17/25 addressed on 3/17/25 04/10/25, 04/11/125 addressed on 04/11/25 05/12/25, addressed on 05/19/25 07/11/25, addressed on 07/15/25 08/11/25, addressed on 08/13/25.Record review of the facility's pest control invoices dated from 02/17/25, 03/16/25, 4/22/25, 5/19/25, 06/16/25, 07/17/25, and 08/13/25, revealed monthly service was rendered. No further details were included in the invoices.Record review of the facility policy and procedure for Pest Control, revised May 2008 read in part: Policy Statement - Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 2. Pest control services are provided by pest control company. 3. Windows are screened at all times 5. Garbage and trash are not permitted to accumulate and are removed from the facility daily. 6. Maintenance services assist, when appropriate and necessary, in providing pest control services. Event ID: Facility ID: 675274 If continuation sheet Page 4 of 4