Health inspection·September 27, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse and neglect for 1 of 4 staff (CNA-B) reviewed for background screenings. Residents Affected - Few The facility failed to provide evidence of completion of an annual EMR for CNA-B. These deficient practices could place residents at risk for abuse and neglect. The findings were: Review of the personnel file for CNA-B with a hire date of 06/06/2022 revealed last EMR was verified on 06/03/2022. During an interview on 09/26/2023 at 10:27 a.m., ADMN stated that EMR's were not verified. He was not aware the facility was supposed to verify EMRs yearly until new company took over the first of September. The failure was that EMR verification did not occur. ADMN stated that the affect on residents would be that not completing annual EMR's could result in staff working in the building that should not be allowed to work. Review of Human Resources Policy and Procedures Manual titled HR-103 TEXAS Background Screening Procedures Effective Date: 4-27-2021 - Supersedes all previous policies on 09/26/2023 revealed Texas i. https://emr.dads.state.tx.us/DadsEMRWeb/emrRegistrySearch.jsp ii. This verifies the following information iii. Misconduct Registry iv. CNA Certification Page 1 of 2 675350 675350 09/27/2023 Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605

F 0607 v. Level of Harm - Minimal harm or potential for actual harm CMA Certification b. Regardless of position ALL Team Members are subject to this verification Residents Affected - Few c. Per state regulations this check must be re-done on all team members anniversary date. 675350 Page 2 of 2