Health inspection·November 10, 2022

F 0558 Record review of Resident #17's annual MDS, dated [DATE], revealed: Level of Harm - Minimal harm or potential for actual harm - a BIMS score of 09 out of 15 which indicated his cognitive status was moderately impaired. Residents Affected - Few Record review of Resident #17's care plan, initiated on 02/18/22 and indicated, in part, Resident #17 is at risk for falling related to debility. Interventions included: assist resident with toileting, transfers, bed mobility as needed. Observation on 11/07/2022 at 11:30 AM revealed Resident #44's call light cord was wrapped around the foot of the bed and was not within the resident's reach. Observation on 11/07/2022 at 11:35 AM revealed Resident #17's call light cord was on the floor, under the resident's bed and was not within the resident's reach. Observation on 11/08/2022 at 9:30 AM revealed Resident #44's call light cord was wrapped around the foot of the bed and was not within the resident's reach. Observation on 11/08/2022 at 9:00 AM revealed Resident #17's call light cord was on the floor, under the resident's bed and was not within the resident's reach. Observation on 11/09/2022 at 8:30 AM revealed Resident #44's call light cord was wrapped around the blankets at the foot of the bed and was not within the resident's reach. Observation on 11/09/2022 at 8:35 AM revealed Resident #17's call light cord was on the floor, under the resident's bed and was not within the resident's reach. During an interview and observation on 11/09/2022 at 9:45 AM RN E stated that Resident #44 was capable of using the call light. RN stated that he had a fall this morning, because he tried to transfer himself to bed on his own. RN E confirmed that the call light was currently wrapped around the blankets at the foot of the bed. RN unwrapped the cord and clipped the call light to the blanket in residents reach when surveyor questioned about call lights being in reach. During an interview on 11/09/2022 at 9:55 AM RN E stated that Resident # 17 was capable of using his call light. Surveyor informed the RN that light has been under the resident's bed for the past 3 days. RN E appeared surprise with information provided, located the call light and clipped the call light to the resident's blanket, within reach of resident. During an interview on 11/09/2022 at 11:45AM, Administrator stated that all staff should be ensuring that call lights are within reach of residents at rounds. Surveyor informed Administrator that call lights were not within reach for 2 residents for 3 consecutive days. The Administrator stated he was disappointed that they were not found by staff or Guardian Angels. The Guardian Angels program assigns an advocate to each resident and are supposed to be rounding on residents at least twice a week to assess if resident's have care needs. The Administrator stated, I'll admit that I have personally have not done an in-service on call lights with my staff. Record review of the Nursing Policies and Procedures dated July 01, 2016 which revealed, When leaving residents room, be sure the call light is placed within the patients/residents reach. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675350 If continuation sheet Page 2 of 7 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 675350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605 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 - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 residents' reviewed for accident hazards/supervision (Residents #9 and #34). The facility failed to ensure CNA D and A demonstrated appropriate transfer techniques while using the mechanical lift for Resident #9. The facility failed to ensure MA B demonstrated appropriate transfer techniques while performing a one-person transfer for Resident #34. These failures could place residents at risk for injuries. Findings included: Review of Resident #9's Resident Face Sheet, undated, documented she was a [AGE] year-old female with diagnoses which included paralysis following a stroke. Review of Resident #9's quarterly MDS assessment, dated 9/5/22, revealed: She had a mental status exam score of 10 of 15 (indicating moderate cognitive impairment) She was totally dependent on two or more people for transfers. Review of Resident #9's care plan, dated 4/9/21, revealed: Resident #9 required lifting with a Hoyer (mechanical) lift to be safely transferred. The long-term goal was Resident #9 will not sustain an injury during mechanical lift. Approaches included: two staff members to transfer and make sure Resident #9's arms and legs are in proper positioning during transfers to reduce the risk of injury to skin. Observation on 11/08/22 at 9:15 AM revealed Resident #9 already in bed position (upon entering room to watch transfer) in her sling. CNA D positioned the shower chair to the bed but did not lock any of the wheels, which could result in the shower chair moving at time of transfer. CNA A operated the lift and did not lock the lift and did not lock the legs as the lift was being used under the bed. Resident #34 Review of Resident #34's Resident Face Sheet, undated, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included pain, arthritis of the knees on both sides, and muscle weakness. Review of Resident #34's care plan, most recently updated 9/22/22 revealed no care plan for Resident #34's transfer status. Review of Resident #34's Significant Change MDS Assessment, dated 9/6/22, revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675350 If continuation sheet Page 3 of 7 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 675350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605 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 She had a mental status of 3 of 15 indicating severe cognitive impairment. Level of Harm - Minimal harm or potential for actual harm She needed extensive assistance of one staff for transfers. Residents Affected - Some Observation on 11/08/22 at 10:47 AM revealed MA B took Resident #34 to her room, lowered the bed, and took off Resident #34's foot pedals. MA B did not lock the wheelchair. MA B put Resident #34's arms on MA B's shoulders. MA B wrapped her arms around Resident #34 (arms located under resident's arms) and stood her up on a count of three. Resident #34 began to lose her balance. The assisting aide (no identifier) grabbed Resident #34 by the waist of her pants to hold Resident #34 up. MA B pivoted Resident #34 and put her to bed. There were two gait belts (used for transfers-assistance safety device used to help a patient sit, stand or walk) hanging on the closet. Interview on 11/09/22 at 12:49 PM PTA C stated a mechanical lift needed two people to operate it. He stated the mechanical lift needed the legs widened to maneuver around the wheelchair and to provide a base of support. He stated if the resident was being moved to a chair, the chair would need to be locked. He stated if a resident could bear weight a gait belt was an appropriate transfer. PTA C said the proper procedure was to position the chair by the bed, lock the brakes, put on the gait belt and have the resident push up on their own, pivot and sit down. He said a hug transfer was not safe because if the resident lost their balance the resident would pull the person transferring to the ground on top of them injuring the resident. PTA C stated that all staff are trained annually (and as needed) for proper transfer techniques with DON or Physical Therapy department. Interview on 11/09/22 at 1:56 PM, ADON said what the facility taught for mechanical lifts was to use two people, ask the resident, roll the resident to each side of the bed to put on the sling, hook up the slings, and then one person controlled the lift while the other stabilized the resident. She said after that they needed move the resident to the chair, they lower the resident and disconnect the sling. The ADON said the wheels needed to be locked on the lift while moving the resident up and down and the chair had to be locked. She said her expectation for a one-person transfer was to use a gait belt was to: lock the wheelchair, lower the bed, tell the resident what was going on, pivot and lower to the bed. The ADON said consequences of not transferring residents this way could cause falls, drops, or injuries. The DON who was present stated she did not know when the last time was an in-service was done on transfers. The DON stated therapy did the training and she had done some during the last CNA class. The DON stated she monitored aides by peeking on them when they did transfers, and she helped with them. The DON said if the instructions for the lift were not on the machine she did not know where they were. Surveyor requested the policy and procedure for transfers as well as the proficiency checklists at this time. The Administrator was present for most of the conversation. Review of the Staff Education/Orientation Standards of Practice checklist, undated, for Hoyer Lift/Transfers revealed: With the legs of the base open and locked, use the steering handle to push the patient into position. Engage the rear wheel locks of the wheelchair to prevent movement of the chair. Review of The Staff Education/Orientation Standards of Practice, undated, for Use of Gait Belt revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675350 If continuation sheet Page 4 of 7 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 675350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605 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 Assist patient/Resident to sitting position on side of bed with chair positioned correctly. Level of Harm - Minimal harm or potential for actual harm Applies gait belt around patient/resident's waist, leaving room for hands to easily slide inside belt. Assures patient/resident is wearing non-skid shoes or socks and has weight bearing leg forward. Residents Affected - Some Stands with feet apart, knees & hips flexed, and aligns knees with patient's resident's knees. Grasps gait belt at sides, rocks patient/resident to standing position on count of three (3). Uses own knee to maintain stability of weak leg and pivots on foot that was farthest from the chair. Instructs patient/resident for proper alignment in sitting position. No policy was provided prior to survey exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675350 If continuation sheet Page 5 of 7 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 675350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605 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, interview, and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for two medication carts of four medication carts (medication cart #1 and #2) reviewed for label and storage of drugs and biologicals. The facility failed to ensure medication carts #1 and #2 were locked when unattended. This failure could place residents at risk of having access to unauthorized medications and unauthorized lab and medical supplies and/or lead to possible harm or drug diversions. Findings included: During an observation on 11/07/2022 at 5:25 PM of the lobby revealed an unlocked medication cart with over-the-counter medications (such as Tylenol) in the top drawer, blister packs of prescription medications in the second drawer, overflow medications cards and liquid over the counter medication in the third drawer. All drawers of the medication cart were unlocked and were easily accessible. The Administrator walked out of his office and came immediately and locked the cart. During an observation and interview on 11/09/2022 at 11:15 AM of the east hall revealed an unlocked medication cart with over-the-counter medications (such as Tylenol) in the top drawer, blister packs of prescription medications in the second drawer, overflow medications cards and liquid over the counter medication in the third drawer. All drawers of the medication cart were unlocked and were easily accessible. CNA D came down the hall and stated, the med aide in charge of this cart is outside with the residents on their smoke break and locked the cart (pushing in the pop out lock mechanism). In an interview on 11/09/22 at 12:30 PM, Med Aide F stated that the medication cart that was left open was hers and she became distracted and walked away without thinking. Med Aide F stated that cart needs to be locked anytime we walk away from the cart so that residents do not get a hold of medications and take medications that do not belong to them. I had over the counter medications, blood pressure medications, Tylenol, NSAIDS, and vitamins in my cart that could be harmful. In an interview on 11/09/11 at 12:45 PM, DON stated that she heard that the surveyors had found medication carts unlocked and unsupervised and stated that she had just had an in service with staff regarding locking medication carts (medication carts should not be left unlocked when not supervised by staff) today and plans to continue in service training quarterly. DON stated that she will perform in-services or will have a charge nurse perform if she is not available. In an interview on 11/09/2022 at 12:55 PM, Administrator stated that medication cart should be locked at all times when unsupervised. Administrator stated, I was very surprised that my most experienced medication aide left her medication cart unlocked. My expectations are that medication carts are locked at all times when not being used by staff. Review of the facility's policy, titled Medication Management Program: Security and Safety Guidelines, revised 07/2021, reflected (in part): (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675350 If continuation sheet Page 6 of 7 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 675350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605 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 The medication cart is to be locked when not in use and in direct line of sight. Keys to the medication room and cart are to be kept with the authorized staff and are the responsibility of the person assigned those keys. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675350 If continuation sheet Page 7 of 7