Health inspection·January 10, 2024

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some [AGE] year-old female admitted on [DATE], a code status of full code, with diagnoses that included: COVID-19 (disease caused by a virus), presence of cardiac pacemaker, muscle weakness, limitation of activities due to disability, and hypertension (high blood pressure). Record review of Resident #202's baseline care plan started on 12/28/2023 revealed RN-DON signed date of 01/01/2024. During an interview on 01/10/2024 at 1:48 p.m., the RNC stated the DON was responsible for completing baseline care plan. The RNC stated that the DON was not working at the time of the interview. The RNC stated her expectation was for baseline care plans to be completed after Social Services, Nursing and Dietary completed their sections. She stated that baseline care plans are completed when RN signed baseline care plan. The RNC stated that she felt that failure to complete in required time frame occurred due to facility having to perform extra tasks related to COVID requirements. During an interview on 01/10/2024 at 2:34 p.m., the RNC stated that she was in the process of performing an in-service on baseline care plans. She stated that this failure could lead to resident's not getting the care that they needed. Record review of facility policy titled; Baseline Care Plans dated 11/08/2016 and revised on 07/16/2023 revealed: Baseline care plans are developed and implemented within 48 hours of a resident new admission. The baseline care plans include measurable objectives to address the resident's immediate medical, clinical, functional, mental, and psychosocial person-centered needs. Baseline care plans are developed by Registered Nurses and other healthcare team members. The LVNs and other healthcare team members execute baseline care plans. Overall care coordination of the resident is evaluated by the DON/designee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675350 If continuation sheet Page 2 of 12 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 01/10/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents were provided respiratory care received care consistent with professional standards of practice for 2 of 2 residents (Resident #11 and Resident #42) reviewed for oxygen administration. Residents Affected - Few The facility failed to provide Oxygen (O2) in use sign on resident doorways for Resident #11 and #42. These failures could place residents at risk of not receiving appropriate respiratory care. Findings included: Resident #11 Record review of Resident #11's electronic face sheet dated 01/10/2024 revealed resident was an [AGE] year-old female originally admitted on [DATE] and most recently admitted on [DATE] with diagnoses that included: dementia (disease of the brain affecting memory and function), acute upper respiratory infection, difficulty in walking, unsteadiness on feet, lack of coordination, chronic obstructive pulmonary disease (lung disease interfering with breathing) and shortness of breath. Record review of Resident #11's physician orders dated 01/07/2024 revealed: O2 @ 2 LPM via NC (nasal cannula). Record review of Resident #11's quarterly MDS dated [DATE] revealed: BIMS score of 12 (meaning moderately impaired) and received oxygen therapy while a resident. Record review of Resident #11's care plan dated 10/03/2023 revealed: Resident uses oxygen therapy routinely or as needed and is at risk for ineffective gas exchange. During an observation on 01/09/2024 at 10:40 a.m., Resident #11 was lying in bed with oxygen being administered via NC from concentrator. There was an oxygen canister not in use secured to the back of wheelchair beside bed. There was no sign on the doorway to indicate oxygen in use. During an observation on 01/09/2024 at 2:13 p.m., Resident #11 was lying in bed with oxygen at 2 LPM being administered via NC from oxygen concentrator. There was no sign on the doorway to indicate oxygen in use. Resident #42 Record review of Resident #42's electronic face sheet dated 01/10/2024 revealed resident was a [AGE] year-old male originally admitted on [DATE] and most recently admitted on [DATE] with diagnoses that included: dementia (disease of the brain affecting memory and function), chronic atrial fibrillation (disease where upper chambers of the heart beat irregular and interferes with blood flow), heart failure (inability of heart to pump blood effectively), and shortness of breath. Record review of Resident #42's physician orders dated 12/18/2023 revealed: O2 @ 2 LPM via NC .as needed related to heart failure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675350 If continuation sheet Page 3 of 12 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 01/10/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #42's quarterly MDS dated [DATE] revealed: BIMS score of 10 (meaning moderately impaired) and no oxygen therapy received. Record review of Resident #42's care plan dated 12/18/2023 revealed: Resident uses oxygen therapy routinely or as needed and is at risk for ineffective gas exchange. Residents Affected - Few During an observation on 01/08/2023 at 1:58 pm., Resident #42 was lying in bed with oxygen at 2 LPM being administered via NC from oxygen concentrator. There was no sign on the doorway to indicate oxygen in use. During an interview on 01/09/2024 at 2:58 p.m., LVN A stated that there should be oxygen sign outside of the room when a resident uses oxygen. LVN A stated that both Resident #11 and Resident #42 had moved rooms recently and he felt that was what led to both residents not having appropriate signage. He was not able to state what the oxygen facility policy stated. During an interview on 01/09/2024 at 3:04 p.m., ADON B stated that residents who use oxygen should have a magnet oxygen in use sign on door frame. She stated that recent resident room changes possibly led to the failure of not having appropriate signage. She did not provide an answer on how the failure could affect the residents. During an interview on 01/10/2024 at 1:48 p.m., RNC stated that there should be sign outside residents' room doors stating no smoking oxygen in use when a resident uses oxygen. She voiced that recent room changes related to COVID requirements led to the failure of proper signs not being outside of residents' rooms. She stated that the facility does not allow for smoking inside the building. She stated that it could be possible for a visitor to not obey the rules. She stated that if someone did smoke in areas where oxygen was used, it could cause a fire. During an interview on 01/10/2024 at 3:12 p.m. ADMN stated that he expected oxygen in use no smoking sign to be placed outside of residents' rooms where oxygen was used. He stated that he felt recent room changes led to the failure of proper signage not being present on door frames. He stated that the effect this could have on residents was it could cause a fire. Record review of facility policy titled Oxygen Administration dated 09/12/2014 revealed: Fundamental Information .Oxygen sign remain on room doorway the entire time the O2 source is in the patient room . Procedure: 1. Verify Physician Order 2. Order should have when to call the physician parameters 3. Assemble equipment 4. Explain procedure and provide privacy 5. Wash hands 6. Place No Smoking Oxygen in sign on the doorway. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675350 If continuation sheet Page 4 of 12 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 01/10/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual nutritional needs for 1 of 1 lunch meal reviewed. The facility failed to ensure the recipe was followed when prepared pureed Seasoned Greens. This failure could place residents at-risk of inadequate nutrition and weight loss. The findings included: Record review of Resident #14's Quarterly MDS dated [DATE] revealed Section A Identification Informaiton- Resident #14 was a [AGE] year old female admitted on [DATE]; Section C Cognitive PatternsResident #14 had a BIMS score of 15 (Cognitively intact); Section I Active Diagnoses- Resident #14 had the following diagnosis cancer, heart disease, malnutrition; Section K- Swallowing/Nutritional status-Resident #14 had a mechanically altered diet. During an interview on 01/08/2024 Resident #14 stated she was on a pureed diet, and puree food was always bad. Resident #14 stated the puree food was gooey and sometimes it tasted like glue. During an observation and interview on 01/09/2024 beginning at 10:00 AM [NAME] A added 6-8 slices of bread to the greens puree. [NAME] A also added warm water, additional bread, and thickener while she prepared the green puree. [NAME] A was observed not using a recipe while she prepared the greens puree. [NAME] A stated she added the bread to greens puree as thickener. [NAME] A stated the recipe called for the bread as the thickener. [NAME] A stated she did not think the bread would change the nutrition value of the greens. [NAME] A stated the bread and water could have taken away from the flavor of the greens. During an interview on 01/09/24 at 10:45 AM the DM stated her expectation was that cooks follow the recipes. The DM stated [NAME] A should not have used bread when she prepared the greens puree. The DM stated she did not know if the bread would have changed the nutrition value of the greens, but that it would have affected the flavor. The DM stated she was responsible for monitoring staff. The DM stated staff were trained by shadowing a tenured cook. The DM stated she did not know what led to the failure of the cook using bread as a thickener. During an interview on 01/09/24 at 03:05 PM the RNC stated adding bread to greens would alter both the nutritional value and the taste. During an interview on 01/10/24 at 02:24 PM the Dietician stated [NAME] A should have followed the recipe and should not have put bread into the greens. The Dietician stated that not following the recipe could have affected the flavor and texture of the food. The Dietician stated she monitors the DM and covers for the DM when she was not in the facility. The Dietitian stated [NAME] A was flustered with surveyors in the kitchen, and that led to failure in the kitchen. During an interview on 01/10/24 at 03:13 PM the ADMN stated staff being in routine, working on auto pilot and nerves led to failure of not following the recipe. The ADMN stated the effect on residents could have been residents received substandard food and food could have been harder to swallow. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675350 If continuation sheet Page 5 of 12 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 01/10/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of facility policy titled Menus and Adequacy dated 10/01/2018 revealed: Menus are planned to meet the average resident's nutritional needs. Record review of facility recipe titled Seasoned Greens, revealed Puree instructions: (Portion size = #8 dipper) Measure 1/2 cup cooked vegetable, 1 TB water for each serving needed into food processor. Blend until smooth. Pour into baking pan, cover, and heat to 165 degrees F before serving. Event ID: Facility ID: 675350 If continuation sheet Page 6 of 12 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 01/10/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations and interviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. Residents Affected - Some The facility failed to ensure that staff sanitized the thermometer while taking temperature of food. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation on 01/08/2024 beginning at 11:30 AM [NAME] C removed the thermometer from the mashed potatoes and placed it in the Beef and Cabbage and then in the gravy. [NAME] C failed to sanitize the thermometer between taking the temperature of each food. During an interview on 01/09/24 at 10:45 AM the DM stated her expectation when taking temperatures of food was the thermometer should have been cleaned with an alcohol swab before placed in a food and after removed from item. The DM stated [NAME] C should have not been dipped into water between each use. The DM stated the cooks were responsible to take the temperatures, but she was responsible to monitor. The DM stated not sanitizing the thermometer could have caused the residents to receive food that was exposed to cross contamination, and they could have gotten sick. The DM did not have an explanation to what led to failure. During an interview on 01/10/24 at 02:24 PM the Dietician stated [NAME] C should have sanitized the thermometer before she placed the thermometer into food. The Dietician stated not properly sanitizing the thermometer could have caused cross contamination. During an interview on 01/10/24 at 3:31 PM the ADMN stated his expectation was the thermometer should have been sanitized before each use. The ADMN stated not sanitizing the thermometer could have led to cross contamination. The ADMN stated staff being in routine and nerves could have led to the failure. During the exit conference on 01/10/2024 at 7:30PM the ADMN and RNC stated they did not have any other polices to provide. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675350 If continuation sheet Page 7 of 12 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 01/10/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurate for 2 (Resident # 8 and Resident # 17) of 5 residents reviewed for resident records. The facility failed to ensure smoking assessments were accurate for Resident #8 and Resident #17. This failure could place residents at risk of having errors in care and treatment. The Findings included: Record review of Resident #8's face sheet dated 01/10/2024 revealed resident was a [AGE] year-old female who was admitted on [DATE] with an original admission date of 02/26/2018 with diagnoses that included: Cerebral infarction (stroke), Major Depressive Disorder, right side paralysis and weakness. Record review of Resident #8's Quarterly MDS dated [DATE] revealed: Section C-Cognitive Patterns Resident #8 had a BIMS score of 7 (severe cognitive impairment); Section GG- Functional Abilities and Goals Resident #8 needs assistance with setup and clean-up while eating and maximal assistance with oral hygiene and requires a wheelchair for mobility. Record review of Resident # 8's smoking assessment dated [DATE] revealed Resident #8 as independent smoker, required no supervision to smoke. Record review of Resident #17's electronic face sheet dated 01/10/2024 revealed resident was a [AGE] year-old female admitted on [DATE] with diagnoses that included: schizoaffective disorder, and anxiety. Record review of Resident #17's quarterly MDS dated [DATE] revealed: BIMS score of 07 (meaning severely impaired); Section G- Resident required supervision for eating, and transfers. Record review of Resident #17's smoking assessment date 09/13/2023 revealed Resident #17 as dependent smoker and required assist/supervision to smoke. Record review of Resident #17's care plan dated 09/15/2023 revealed Resident was a Dependent smoker: This resident is a dependent smoker and requires staff supervision to reduce the risk for smoking related injuries. Record review of Resident #17's smoking assessment date 12/14/2023 revealed Resident #17 as independent smoker, required no supervision to smoke and BIMS score was equal to or greater than 12. Record review of Resident #17's care plan dated 09/15/2023 revealed Resident was a Dependent smoker: This resident is a dependent smoker and requires staff supervision to reduce the risk for smoking related injuries. During an interview on 01/10/2024 at 5:45 PM the RCN stated the expectation was residents' smoking (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675350 If continuation sheet Page 8 of 12 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 01/10/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assessments be completed accurately. The RNC stated if Resident's BIMS was below a 12 then resident should score as a supervised smoker. The RNC stated the assessments for Resident #17 and Resident #8 were wrong if stated they were unsupervised smokers because they should have been supervised smokers. The RNC stated the Social Worker was responsible for completing the Smoking Assessments. The RNC stated what led to failure of smoking assessments being wrong was a nurse that worked the night shift decided to complete the assessments one night on her shift. The RNC stated the effect on residents could have been residents not receiving appropriate supervision. Record review of facility policy titled, Maintenance of Electronic Clinical Records dated 08/13/2019 revealed A complete and accurate electronic clinical record will be maintained on each resident and kept accessible and systematically organized for appropriate personnel to deliver the appropriate level of care for each resident while maintaining the confidentiality of the residents' information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675350 If continuation sheet Page 9 of 12 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 01/10/2024 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 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 interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for infection control procedures for 3 of 5 (#4, #17, and #44) residents reviewed for infection control. Residents Affected - Some The facility failed to follow their Infection Control policy regarding CDC guidelines of performing the Flu test in conjunction with their COVID-19 testing. this failure could place residents at risk of the spread of infections. Findings included: Resident #4 Record review of Resident #4's electronic face sheet dated 01/10/2024 revealed resident was an [AGE] year-old female originally admitted on [DATE] and most recently admitted on [DATE] with diagnoses that included: COVID-19, Streptococcus Pneumoniae (a bacteria commonly inhabited in the respiratory tract). Record review of Resident #4's physician orders dated 01/07/2024 revealed: Perform COVID-19 antigen test with a start date of 11/19/2023. Record review of Resident #4's quarterly MDS dated [DATE] revealed: BIMS score of 01 (meaning severely impaired). Record review of Resident #4's care plan dated 10/04/2023 revealed: Resident has diagnoses of a viral respiratory infection (COVID 19, RSV, Influenza) and is a risk for: Respiratory complications (including impaired oxygen exchange). Resident #17 Record review of Resident #17's electronic face sheet dated 01/10/2024 revealed resident was a [AGE] year-old female admitted on [DATE] with diagnoses that included: COVID-19 and chronic obstructive pulmonary disease (lung disease interfering with breathing) and shortness of breath. Record review of Resident #17's physician orders dated 01/10/2024 revealed: Perform Covid-19 antigen test with a start date of 09/04/2023. Record review of Resident #17's quarterly MDS dated [DATE] revealed: BIMS score of 07 (meaning severely impaired). Record review of Resident #17's care plan dated 01/05/2024 revealed: Resident has dx of a viral respiratory infection (COVID 19) and is a risk for: Respiratory complications (including impaired oxygen exchange) Resident #44 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675350 If continuation sheet Page 10 of 12 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 01/10/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #44's electronic face sheet dated 01/10/2024 revealed resident was an [AGE] year-old male admitted on [DATE] with diagnoses that included: COVID-19, ALZ (disease of the brain affecting memory and function), and respiratory disorder. Record review of Resident #44's physician orders dated 01/10/2024 revealed: Perform Covid-19 antigen test dated 09/07/2023, and Covid-19 antigen test dated 11/19/2023. Record review of Resident #44's quarterly MDS dated [DATE] revealed: BIMS score of 99 (meaning severely impaired). Record review of Resident #44's care plan dated 10/03/2023 revealed: Resident has dx of a viral respiratory infection (COVID 19) and is a risk for: Respiratory complications (including impaired oxygen exchange). An interview on 01/09/2024 at 9:10 AM the RNC stated one resident was tested this day due to showing signs and symptoms. She stated the facility staff followed CDC guidelines which was stated in their policy. The RNC stated they had not tested residents or staff for the flu while testing for COVID. An interview on 01/09/2024 at 04:24 PM the ADMN stated he had not reviewed the CDC guidelines recently, but the DON and ADON-B most likely had. He stated he did not know if the flu test had been performed on the residents when they performed the COVID test and had not realized those two tests needed to coincide with each other. In an interview on 01/10/24 10:20 AM the RNC stated she was not aware the flu and covid test needed to coincide or performed at the same time. She stated the ADON-B and the DON, if in the facility had tested the residents and staff, but if they were unavailable to do so, she herself (RNC) helped out and monitored Infection Control. The RNC stated they had a policy committee that met every 2 months to review the updated CDC guidelines. She stated she felt the negative impact to the residents would have possibly having/getting the flu or spreading the current illness. She stated she was not sure what she would do differently. The RNC stated the failure was not following CDC guidelines and not having performed the flu test to coincide with the COVID test. She stated her expectations were for staff to follow facility policies with CDC guidelines. Record Review of Facility policy COVID-19 Visitation dated 10/24/2022, with the revised date of 05/11/2024 revealed: Exceptions will be in accordance with current CDC recommendations, or as directed by state government 4. The core principles of COVID-19 infection prevention will be adhered to and as follows: . .j. The facility will conduct resident and staff testing as current CDC guidance. Record Review of Facility policy Novel Coronavirus Prevention and Response dated 03/07/2022 and last revised date of 05/11/2023 revealed: This facility will respond promptly upon suspicion of illness associated with a novel coronavirus in efforts to identify, treat, and prevent the spread of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675350 If continuation sheet Page 11 of 12 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 01/10/2024 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 0880 virus, and for other causes of respiratory illness, such as influenza or other respiratory panels. Level of Harm - Minimal harm or potential for actual harm Record CDC Guidelines title Testing and Management Considerations for Nursing Home Residents with Acute Respiratory Illness Symptoms when SARS-CoV-2 and Influenza Viruses are Co-circulating accessed on 11/14/2023 at https://www.cdc.gov/flu/professionals/diagnosis/testing-management-considerations-nursinghomes.htm revealed: Residents Affected - Some 2. Test any resident with symptoms of COVID-19 or influenza for both viruses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675350 If continuation sheet Page 12 of 12