Health inspection·February 27, 2025

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. 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 review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 1 of 10 residents (Resident #50) reviewed for resident rights. Residents Affected - Few The facility failed to obtain a signed consent for admission to reside onto the facility's Memory Care Unit. This failure could affect residents who were placed and received care placed on the Memory Care Unit without informed consent. Findings included: Review of Resident #50's Face Sheet revealed a [AGE] year-old female initially admitted on [DATE] with a recent admission date of 09/04/2024. Resident #50's medical diagnoses included: need for assistance with personal care, cognitive communication deficit, dementia, psychotic disturbance, mood disturbance, and anxiety disorder. Review of Resident #50's annual MDS dated [DATE] revealed in Section C - C0500, BIMS Summary Score, a BIMS score of 00 indicating the resident was unable to complete the interview. Review of Resident #50's Comprehensive Care Plan initiated 09/09/2024 and revised on 10/08/2024 revealed the following focused areas: *Behavioral Problem: Resident has a behavior problem as evidenced by agitation and yelling at others. An Intervention for the focus on behavioral problems included using an Intervene as necessary to protect the rights and safety of others, remove resident to an alternate location when needed to protect the rights and safety of others by offering to sit outside or activity in room. *Wandering/exit Seeking: Resident wanders related to cognitive impairment and is at risk for injury related to: Dementia. An Intervention for the focus on wandering/exit seeking included: Attempt to determine any pattern or cause of wandering, reassure resident when distressed over placement, mark room door with a familiar object, to remember room location as indicated. *Secured Unit: Resident resides in a secured unit related to cognitive impairment/elopement risk secondary to Dementia Date initiated 06/27/2024, with a revision date 10/08/2024. An Intervention for the focus on behavioral problems included, Monitor for adjustment to a new environment. Place resident within the facility according to their cognitive and functional abilities. Page 1 of 23 675350 675350 02/27/2025 Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605

F 0552 Level of Harm - Minimal harm or potential for actual harm Review of Resident #50's physician orders reviewed on 02/21/2025 revealed: May admit to a secured unit for specialized dementia care, dated 9/4/2024. Review of Resident #50's consents revealed there was no signed consent by resident or resident Representative, in her EMR, to be admitted on to the facility MCU. Residents Affected - Few During an interview on 02/27/2025 at 9:35 AM, HR stated there was no documentation of a consent for Resident #50 for the MCU. She stated all MCU residents should have had a consent signed and documented . During an interview on 02/27/2025 at 9:40 AM, the DON stated Resident #50 had no consent in her paper file nor in her electronic charting. She stated it was protocol for all residents on the MCU to have a signed consent on file prior to being admitted to the unit. The DON stated she would get a consent from Resident #50's daughter immediately which would be a verbal. She stated that would be the only way to retrieve the consent until her was in town for a visit. She stated Medical Records had the consents signed upon admission, but that position had not been consistent with being filled. She stated, the failure occurred with personnel and not having checked on the paperwork for proper completion. The DON stated the resident impact for not having a consent would have possibly been that residents being placed in an area that was locked and unable to have the same right as other residents. She stated her expectation was for all paperwork to be completed in a timely manner where and when needed. During an interview on 2/27/2025 at 10:16 AM the RNC stated, it was the admission Coordinators responsibility to have all resident paperwork completed prior to being placed on the MCU but there was not one available. The RNC stated it was then MR's responsibility, but that position had recently been open as well. She then stated it was ultimately the Administrator who should have overseen the process of making sure the consents were signed. The RNC stated the negative impact for Resident #50, could have been potentially a Resident Rights issue. The RNC stated the failure occurred with facility personnel changes with her expectation was for all residents to have consents prior to being admitted to the MCU. During an interview on 02/27/2025 at 10:39 AM the ADMN stated the protocol for being admitted to the MCU was to have a consent signed prior to being admitted into the MCU. He stated the SW and nursing staff as well as the ADMN were the staff who monitored. The ADMN stated he did not feel there was a negative impact for this particular one, she was back there at the request of her family, and she did not mind being back there. He stated the protocol was not followed, but the family wanted her there. The ADMN stated the failure occurred on admission, with his expectation for the facility to have reached out to the Resident Representative for the consent to be signed and available. Record Review of the facility policy admission criteria for Secured Continuous Care Unit, dated with origination date of 01/10 and Review date of 5/16/24, revealed Policy- an admission to the Secured Continuous Care Unit will be performed in a uniform manner. Residents eligible for admission to an SCCU will have a diagnosis of Alzheimer's, Dementia, or related disorders. Residents with cognitive impairment who may have unsafe wandering or exit seeking may meet eligibility for admission to an SCCU. The need for admission must be documented by the attending Physician Assessment Tools for admission to SCCU- .6. Secure Continuous Care Unit Acknowledgement Form. 675350 Page 2 of 23 675350 02/27/2025 Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605

F 0570 Assure the security of all personal funds of residents deposited with the facility. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record review, the facility failed to purchase a surety bond, or otherwise provide assurance satisfactory to the secretary, to assure the security of all personal funds of residents deposited with the facility for 1 of 1 surety bonds reviewed. Residents Affected - Some The facility failed to ensure that the facility's $30,000.00 surety bond was enough to cover the $32,6635 total residents' trust fund account balance. This deficient practice could affect all residents who deposited personal funds with the facility, and place residents at-risk of their personal funds not being assured. The findings included: Record review on 02/27/2025 of the facility's Bond Execution Report revealed bond amount $30,000 processed date 06/04/2024. Record review 02/27/2025 of facility's Bank Account Statistics Report with date range 10/01/2024 to 12/31/2024 revealed average balance $32,266.35. During an interview on 02/27/2025 at 3:10 PM the ADM stated he did not know why the surety bond amount was less than the average balance reported. The ADM stated it could be to the transition to Deluxe Health Care now being a consultant. The ADM stated the amount of the surety bond could be incorrect due to an increase in the census. The ADM stated he did not feel this affected residents in any way . Record review of the facility's policy titled: Resident Trust Fund Policies last revision date of 02/2006. The trust fund account must be identified as Trustee, (name of facility), Resident's Trust Fund Account. The Trust Fund Account must be an interest-bearing account that is separate from any of the facility's other accounts. Surety Bond The facility is required to carry a surety bond on the cumulative total of all residents' trust fund balances. The required amount should be calculated using the Surety Amount Calc form. The Surety bond must equal the average monthly balance of all the facilities resident's trust fund accounts for the 12-month period preceding the bond issuance or renewal dates. Resident Trust Fund accounts are specific only to the single facility purchasing a resident trust fund surety bond 675350 Page 3 of 23 675350 02/27/2025 Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care plan and provide a summary of their baseline care plan to residents for 1 (Resident #168) of 10 residents reviewed for care plan completion. The facility failed to complete Resident #168's baseline care plan within the required 48-hour timeframe. This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified. Findings included: Review of Resident #168's Face Sheet revealed a [AGE] year-old male admitted on [DATE]. Resident #168's medical diagnoses included COPD (Chronic Obstructive Pulmonary Disease), alcohol dependence, nicotine dependence chronic pain, respiratory failure, and homelessness. Review of Resident #168's Annual MDS dated [DATE] revealed in Section C - C0500, BIMS Summary Score, a BIMS score of 15 (cognitively intact). During an interview on 02/26/2025 at 6:52 PM the DON stated her expectation was that baseline care plans were to be completed within 48 hours of admission. The DON stated it was her responsibility to complete and monitor the completion of the baseline care plans. The DON stated the residents could have been affected by the baseline care plan not being complete timely by their care needs not being met. The DON stated what led to the failure was Resident #168 was admitted on Friday evening and she had missed completing the baseline care plan within the 48 hours. Review of the facility policy titled, Baseline Care Plans dated 11/8/2026 revealed, Baseline care plans are developed and implemented within 48 hours of a resident new admission. 675350 Page 4 of 23 675350 02/27/2025 Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605

F 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record review, the facility failed to ensure the activities program was directed by a qualified professional who was a therapeutic recreation specialist or an activity professional for 1 of 1 activity director (AD) reviewed for qualifications. Residents Affected - Some The facility failed to ensure the AD was a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements. This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident. The findings included: Review of the AD's employee file revealed the AD took the position on January 27, 2025, and had no evidence of certification or training as a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements. During an interview on 02/25/2025 at 4:00 PM the AD stated she was new to the facility, and she had started on 01/25/2025. The AD stated she had not received her AD certification at this time and was working on her AD certification . During an interview on 02/27/2025 at 11:53 AM the ADMN stated his expectation was to have a licensed Activity Director. The current AD was not certified, and she came from a sister facility where she was as an assistant AD. The ADMN stated he was responsible to ensure the AD was certified. The ADMN stated he did not feel there was an effect on residents, because the AD had previous experience and had a good rapport with residents. The ADMN stated what led to failure was out of the candidates she was the best candidate and none of the applicants were certified. Review of the facility's job description for the Activity Director revealed, qualifications: a degree and license and recreation therapy from an accredited school. Or a high school diploma or equivalency certificate with two years of experience in social or recreational programs within the last five years, one year which was full time and a patient activities program at a healthcare setting. Successful completion on a state approved and certified course of instruction and patient activities. An individual who is exempt from completion for the state approved course is: a person employed full time in the activity's director position since January 1st, 1976 or a person who successfully completed a minimum of 36 hours activities director course prior to August 31st1978, which is sponsored by an accredited educational institution our professional group or association. 675350 Page 5 of 23 675350 02/27/2025 Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605

F 0689 Level of Harm - Immediate jeopardy to resident health or safety 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 observations, interviews, and record review, the facility failed to maintain hot water below 110°F for 5 of 8 (Resident #60's sink, RM17 E sink, East Hall shower room sink, Resident #168, Resident #167, and Resident # 14's shared sink and RM [ROOM NUMBER] E sink) bathroom reviewed for water temperature. 1. The temperature of sink in RM [ROOM NUMBER]E was 150°F. 2. The temperature of the East Hall Shower Room Resident 150°F. 3. The temperature of Resident #168, Resident #167, and Resident #14's shared sink was 140°F. 4. The temperature of Resident #60's sink was 136.4°F. 5. The temperature of sink in RM [ROOM NUMBER]E was 125.2°F. 6. The shower water temperature fluctuated, becoming hotter during use for Resident #23 and Resident #1 An Immediate Jeopardy (IJ) situation was identified on 02/25/2025. The IJ template was provided to the facility on [DATE] at 5:00pm. While the IJ was lowered on 02/27/2025 at 5:11 PM, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm, with a scope of a pattern, due to the facility's need to evaluate the effectiveness of their corrective actions. This failure could place residents at risk for 3rd degree burns causing serious injury, serious harm, hospitalizations, impairment, and/or death. Findings included: Resident #60 Review of Resident #60's Face Sheet revealed an [AGE] year-old female admitted on [DATE]. Resident #60's medical diagnoses included psychotic disorder with hallucinations, blood clots in the legs, back pain, difficulty walking, right shoulder pain, weakness, night terrors, and impaired cognition. 675350 Page 6 of 23 675350 02/27/2025 Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #60's Annual MDS dated [DATE] revealed in Section C - C0500, BIMS Summary Score, a BIMS score of 07 (severe impairment). During an observation and interview on 02/24/2025 at 3:45 PM, Resident #60's Family Representative stated the water in the restroom was sometimes too hot. The temperature was taken of hot water, and it was under 110°F. Residents Affected - Some Resident #168 Review of Resident #168's Face Sheet revealed a [AGE] year-old male admitted on [DATE]. Resident #168's medical diagnoses included COPD (Chronic Obstructive Pulmonary Disease), alcohol dependence, nicotine dependence chronic pain, respiratory failure, and homelessness. Review of Resident #168's Annual MDS dated [DATE] revealed in Section C - C0500, BIMS Summary Score, a BIMS score of 15 (cognitively intact). During an observation and interview on 02/24/2025 at 3:08 PM, Resident #168 was sitting on his bed in his room. He stated the water gets hot sometimes, and it will burn you. Resident #168's water was warm to touch. Resident #23 Review of Resident #23's Face Sheet revealed a [AGE] year-old female initially admitted on [DATE] with a recent admission date of 11/28/2024. Resident #23's medical diagnoses included muscle weakness, insomnia, edema (swelling), urinary tract infection, dependent on renal dialysis, mild dementia, diabetes, and lack of coordination. Review of Resident #23's Annual MDS dated [DATE] revealed in Section C - C0500, BIMS Summary Score, a BIMS score of 13 (cognitively intact). During an interview on 02/25/25 at 3:04 PM, Resident #23 stated the shower water was sometimes too hot having to readjust the water temperatures often. She stated she needed help with the set-up for her showering but then would bathe herself. She stated that during her shower the water temperature would increase. During an observation on 2/25/2025 at 4:34PM, the water in RM [ROOM NUMBER] E sink was hot to touch and steam was observed coming off water, the water temperature was 150°F; at 4:41 PM the East Hall shower room sink was at 150°F; and at 4:43 PM Resident #168 Resident #167, and Resident # 14's shared sink was 140°F. During an observation and interview on 02/25/2025 between 5:40 PM and 6:00 PM, the ADMN checked the temperature of random resident sinks to test temperatures. The ADMN stated water temperatures should be between 100°F and 110°F and that if above 110°F degrees it could have led to injury. The ADMN stated the temperature of water in Resident #60's sink was 136.4°F and RM [ROOM NUMBER]E was temperature of 125.2°F. During an interview on 02/25/2025 at 7:05 PM, Resident #1 stated her water in her sink gets really hot. Resident #1 stated she would turn on her cold water to make the water cooler. Resident #1 stated she had not made a complaint about how hot the water was because she could just turn her cold 675350 Page 7 of 23 675350 02/27/2025 Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some water on. She stated that during her shower once the temperature was regulated, the water would get hotter at times, and she would have to ask for assistance to readjust the water. During an interview on 02/25/2025 at 5:00 PM, the MM stated the facility had been having issues with the temperature gauge on the boiler mixer since the plumber had installed a new pump, that circulated water to the facility. The MM stated the arrow on the temperature gauge continued to bounce back and forth within the red range and above the red range and did not know what it meant or why it was doing it. The MM stated the plumber had been in and out of facility the past few months. The MM stated he used a digital probe thermometer and, the last time he tested water temperatures were on 2/21/2025. The MM stated he picked random rooms and all shower rooms to check weekly and documented temps in his electronic system. The MM stated he typically took the water temperatures in the afternoon after resident showers. The MM stated he had not received any complaints of the water being too hot. The maintenance stated water temperatures were not to be over 110°F. During an interview on 02/25/2025 at 6:30 PM, the DON stated if the water temperatures were over 110°F, it was too hot. The DON stated any temperature over 110°F would be a risk for burn. During an interview on 02/25/2025 at 6:33 PM the Regional Nurse stated in her nursing judgment anything over 130°F would be dangerous and could have caused the resident injury. The Regional Nurse stated water temperatures should have been below 110°F. During an interview on 02/26/25 at 11:15 AM one of the plumbers, working at the facility, stated he had been at the facility numerous times. He stated the previous maintenance man had stated they had been having issues for over 5 years. They first replaced the mixing valve, several months ago. He stated that they would adjust things and it would work for a while and then have to come back and check things again. He replaced the pump that circulated the water into the building previously and they were still having issues with how the water was being distributed through the building. The plumber stated he was going to add a second pump to see if this would help with how water was being distributed. The plumber stated this could have caused the water from the mixer to not stabilize. He stated there should have been a little fluctuation with the temperature on the gauge but should not have been fluctuating in and out of the red zone. He stated when the arrow was out of range it could have meant the water was over 140°F. During an interview on 02/27/25 at 1:35 PM the ADMN stated his expectation was that water temperatures should not exceed 110°F. The ADMN stated the MM was responsible to monitor water temperature and he was to report to the AMDN. The ADMN stated the effect on residents of water being too hot was it could have injured residents due to scalding. The ADMN stated what led to the failure was the actual boiler and chiller through the years have been co-mingled and the system began to fail. The ADMN stated in reality the plumbing companies have been monitoring the situation and the issues got ahead of them. Record review of the facility maintenance log between January 31, 2025, and February 24, 20205 there was no time stamp of when temperatures were taken. Not all rooms had temperature taken and the same rooms were checked each week. There were 12 out of 33 resident rooms where temperatures had not been taken during the four-week time frame. The following dates had temperatures above 110°F: on 01/31/2025 RM [ROOM NUMBER]E was 110.1°F and the East Hall Nurses Station was 110.7°F; on 02/06/2025 the East Hall shower room was 111°F, the East Hall Nurses Station was 110.3°F and RM [ROOM NUMBER] East and RM [ROOM NUMBER] East shared bathroom was 110.7°F; on 02/18/2025 the East Hall Nurses Station was 110.4 and RM [ROOM NUMBER] East and RM [ROOM NUMBER] East shared bathroom 675350 Page 8 of 23 675350 02/27/2025 Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605

F 0689 was 110.5. Level of Harm - Immediate jeopardy to resident health or safety Review of US Consumer Product Safety Commission Avoiding Tap Water Scalds accessed on 02/26/2025 at http://efaidnbmnnnibpcajpcglclefindmkaj/https://www.cpsc.gov/s3fs-public/5098.pdf revealed: Most adults will suffer third-degree burns if exposed to 150 degree water for two seconds. Burns will also occur with a six-second exposure to 140-degree water or with a thirty second exposure to 130-degree water. Even if the temperature is 120 degrees, a five-minute exposure could result in third-degree burns. Residents Affected - Some This was determined to be an Immediate Jeopardy (IJ) on 02/26/2025 at 4:31 PM. The Administration was informed of the IJ. The Administrator was provided with the IJ template on 02/26/2026 at 5:00 PM. Record review of Plan of Removal accepted on 04/27/2024 at 1:33 PM reflected the following: Tag Cited: F_689 Issue Cited: Failure to maintain an environment that was free from accidents and hazards 1. Immediate Action Taken A. On 2/25/2025 the maintenance director turned off all hot water in all resident rooms B. On 2/25/2025 all shower rooms were secured by the Maintenance Director with key codes/or pad locks and do not enter signs were placed on the door taking them out of service until further notice. C. On 2/25/2025 all staff were in-serviced that hot water was turned off in resident rooms, and all shower rooms were secured and out of service D. On 2/26/2025 the hot water issues were fixed by the Plumbing company at 4:30 pm. The issues were fixed by adding 2 new recirculating pumps, by re-routing the plumbing to the mixing valve, and by adding 2 new thermostats (1 to the water coming into the mixing valve, and 1 coming out of the mixing valve). The Maintenance Director completed testing all hot water in all resident rooms and shower rooms at 7:00 pm with no hot water temperatures found to be above 110 degrees. E. 675350 Page 9 of 23 675350 02/27/2025 Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605

F 0689 On 2/26/2025 the DON/Designee completed head-to-toe skin assessment for residents 60, 168, 167, and residents #14 and no skin issues identified Level of Harm - Immediate jeopardy to resident health or safety F. Residents Affected - Some On 2/27/2025 at 7:09 am, while testing hot water Temps. It was noted that the facility had hot water temps. Above 110 degrees, so all hot water was again immediately turned off. The Plumbing Company was immediately notified. G. On 2/27/2025 all staff were alerted that hot water would again be shut off to the facility. 2. Identification of Residents Affected or Likely to be Affected: A. On 2/26/2025 the DON/Designee completed head-to-to-toe skin assessment for all other residents throughout the facility, and no issues identified. This was completed on 2/26/2025 at 5:43pm. 3.Actions to Prevent Occurrence/Recurrence: A. On 2/25/2025 the DON/Designee began in-service education with all staff on: This training was completed at 7:00 pm on 2/25/2025 and no staff were allowed to work until they complete this training. Hot water is being turned off on all resident sinks, shower rooms are not to be used, do not turn on hot water in resident rooms. This was completed on 2/25/2025, and no staff were allowed to work until they completed this education. Ensure doors to shower rooms are kept closed at all times to prevent residents from entering unattended. This was completed on 2/25/2025, and no staff were allowed to work until they completed this education. Starting 2/26/2025 This education will be provided for all new hires and any agency staff going forward as part of new hire orientation. B. On 2/26/2025 The Regional Nurse consultant provided 1:1 in-service with the Maintenance Director regarding the hot water system and taking and recording hot water temperatures: Every hour x 4 hours, then twice daily x 3 days, then daily x 7 days then resume the weekly water 675350 Page 10 of 23 675350 02/27/2025 Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some temp. testing. If at any time the hot water temp. exceeds 110 degrees, the hot water will be turned off, The Plumber will be notified for repairs/services, and the monitoring process above will continue until the hot water temperatures remain between 100 and 110 degrees. On Schedule of checking hot water temps. Weekly, rotating rooms, bathrooms etc., ensuring that all rooms and shower room hot water temps are taken and recorded during the month and hot water temperatures remain between 100 and 110 degrees. C. On 2/26/2025 DON/Designee start in-service training with all staff related to: a. Hot water is being turned off on all resident sinks, shower rooms are not to be used, do not turn on hot water in resident rooms. This was completed on 2/26/2025, and no staff were allowed to work until they completed this education. b. Ensure doors to shower rooms are kept closed at all times to prevent residents from entering unattended. This was completed on 2/26/2025, and no staff were allowed to work until they completed this education. c. To turn hot water off immediately and notify charge nurse if at any time water temps. Feel too hot. The nurse in charge will immediately contact the facility administrator so this issue can be addressed immediately. This was completed on 2/26/2025 and no staff were allowed to work until they complete this education. D. All hot water temperature logs will be reviewed daily by the Facility administrator/Designee in the morning meeting to validate facility remains in compliance and no residents are affected related to water temperatures being too hot. E. If at any time during hot water temperature monitoring, any temperature reading is above 110 degrees, the hot water will be shut off to all resident rooms and shower rooms, a plumbing company will be notified to address the issue, and the facility will then monitor hot water temps. Again, every hour x 4 hours, then twice daily x 3 days, then daily x 7 days then resume the weekly water temp. testing. F. On 2/27/2025, the Plumbing Service arrived at 8:30am to correct hot water temperatures, and this will be completed at 1:15 pm 2/27/2025. 675350 Page 11 of 23 675350 02/27/2025 Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605

F 0689 On 2/25/2025 the facility conducted an Ad Hoc meeting to include the medical director regarding hot water temp. issues identified, including an action plan. Level of Harm - Immediate jeopardy to resident health or safety On 2/26/2025 the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to Hot Water Temps. and reviewed a plan to sustain compliance Residents Affected - Some Date Facility Asserts Likelihood for Serious Harm No Longer Exists: _______2/27/2025_________ Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record review from 02/27/2025 at 1:45 PM to 02/27/20254 at 5:11 PM as follows: During an Observation on 2/25/2025 at 7:30 PM all resident sinks had water turned off and shower rooms had been locked with signs placed on the doors that stated see nurse before entering. During an observation on 2/25/2025 at 7:30 PM all shower rooms had been secured and signs on the doors stated, See nurse before entering. During an observation on 02/27/2025 at 2:32 PM staff were alerted with signs being placed and observed on all locked shower doors on East and [NAME] Halls. During an interview on 2/27/2025 at 2:49 PM, on the day shift, CNA E stated she was in-serviced over what to do if she felt the water was too hot. She stated if she was giving a resident a shower, she would check the water temperature first before letting the resident under it. She stated if it was too hot, she would not have the resident in the shower, and she would let the ADMN and maintenance know. CNA E stated she would do the same with the resident sinks. During an interview on 02/27/2025 at 2:59 PM, on the day shift, CNA F stated he would turn the water off if it were too hot, notify the nurse, then he would notify the ADMN. During an interview on 02/27/2025 at 3:02 PM, on the day shift, CNA G stated if she felt the water was too hot or if the resident stated to her it was too hot she would immediately turn it off, assess the resident if needed, then report to the charge nurse, the ADMN and maintenance. During an interview on 02/27/2025 at 3:10 PM, on the day shift, the ADON stated she was in-serviced over what to do if the hot water was too hot in the resident showers and sinks. She stated she should turn off the hot water immediately, and notify the ADMN, maintenance, and the nurse on duty. During an interview on 02/27/2025 at 3:12 PM, on the day shift, LVN D stated she was in-serviced over what to do if the hot water temperature was too hot. She stated if she felt it was too hot, she would immediately notify the charge nurse, the ADMN, and the maintenance man. After turning the hot water off, she would also assess the resident and notify other staff members. During a phone interview on 02/27/2025 at 3:32 PM, CNA H from the night shift, stated she was informed on 02/25/2025 on her shift about the hot water being turned off and to not do any showers until further notice. CNA H stated she had been in-serviced on if the water in the showers or resident sinks felt too hot to turn it off. She stated she would then tell the charge nurse, the ADMN, the DON and maintenance. CNA H stated she was told if she saw there were signs on the shower doors to see the charge nurse. During a phone interview on 02/27/2025 at 3:35 PM, CNA I from the night shift, stated she was told 675350 Page 12 of 23 675350 02/27/2025 Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some the night of 02/26/2025 about the hot water being turned off and to not give the residents showers until further notice. CNA I stated she had been in-serviced on, if giving showers and she felt the hot water was too hot, to turn it off and tell the charge nurse, the DON, the Administrator, and maintenance. During a phone interview on 02/27/2025 at 4:09 PM, RN A who alternated between day and night shifts, stated she had received in-services on if the water in the showers were too hot, she should turn it off, perform a head-to-toe assessment on the resident, notify the DON, the ADMN, and maintenance. RN A stated there were signs placed on the shower door that said, do not enter see nurse. During an interview on 02/27/2025 at 4:52 PM, LVN J stated she was told the previous night about the water had been turned off and not to give the residents showers. LVN J stated she was in-serviced on if the water in the showers or resident sinks were too hot, to turn off the water, then she would be responsible for doing a skin assessment on that resident if needed. LVN J stated she would then call the ADMN and maintenance to inform them the water was too hot. During an interview on 02/27/2025 at 2:52 PM, the MM stated he was in-serviced on hot water, and what to do if he found it to be above 110°F. He stated he would immediately turn it off and proceed to call the ADMN as well as corporate, and the plumbing company. During an interview on 02/27/2025 at 2:44 PM the DM stated she was in-serviced on the hot water. If water was steaming to not place hands under water, especially residents, and if noticed that it was steaming, she would turn the water off and notify the nurse in charge, and the MM of the situation. The DM stated she would also update the ADMN as well. The water should be no higher than 110°F. During an interview on 02/27/2025 at 2:46 PM, the DA stated he was also in-serviced on the hot water and to turn it off if he found it to be too hot for the residents. He stated he was told to notify upper management if the hot water was higher than 110°F . Record review of the facility provided staff in-services revealed staff were provided an in-service on 02/25/2025, 02/26/2025, and 02/27/2025 related to water temperatures being over 110°F and showers being locked. Record review of receipt from Plumber 1 revealed services were rendered on 02/26/2025 and 2/27/2025. Record review of the facility provided temperature logs for 02/26/2025 at 7:00 PM, revealed temperatures were taken at 7:00 PM and were below 110°F. Record review revealed the MM was provided in-services on 02/26/2025 and 02/27/2025. Record review of facility provided water temperature logs revealed the temperatures were checked every 4 hours starting on 02/26/2025 at 7:30 PM until 2/27/2025 at 6:30 AM. Record review of the receipt from Plumber 2 revealed services were rendered on 02/27/2025. Record review of facility provided skin assessments revealed on 02/26/2025 Resident #60, Resident #168, Resident #167, Resident #14, Resident #37, Resident #50, and Resident #38 received a 675350 Page 13 of 23 675350 02/27/2025 Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605

F 0689 head-to-toe assessment, and no issues were noted. ? Level of Harm - Immediate jeopardy to resident health or safety An Immediate Jeopardy was identified on 02/26/2025. While the Immediate Jeopardy was removed on 02/27/2025, the facility remained out of compliance at a level of no actual harm with a potential for more than minimal harm and a scope of pattern, due to the facility monitoring the effectiveness of their Plan of Removal. The ADMN, the DON, and the RRN were informed of the Immediate Jeopardy was removed on 02/27/2025 at 5:11 PM. Residents Affected - Some 675350 Page 14 of 23 675350 02/27/2025 Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605

F 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. 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 review the facility failed the ensure physician visits were conducted within 2-7 days of admission, once every 30 calendar days for the first 90 calendar days for 3 of 24 residents (Resident #22, Resident #23, and Resident #50) who were review for physician visits. Residents Affected - Some 1. The facility failed to have Resident #22 seen by a physician within 2-7 days of readmission [DATE]), once every 30 calendar days for the first 90 calendar days. 2. The facility failed to have Resident #23 seen by a physician within 2-7 days of readmission [DATE]), once every 30 calendar days for the first 90 calendar days. 3. The facility failed to have Resident #50 seen by physician within 2-7 days of readmission [DATE]), once every 30 calendar days for the first 90 calendar days. This deficient practice could lead to a decline in health status or untreated conditions. Findings included: Resident #22 Review of Resident #22's Face Sheet revealed a [AGE] year-old female initially admitted on [DATE] with a recent admission date of 07/31/2024. Resident #22's medical diagnoses included Alzheimer's disease, COPD, type 2 diabetes, major depressive disorder with psychotic symptoms, generalized anxiety disorder, muscle weakness, difficulty walking, and contact with and (suspected) exposure to other viral communicable diseases. Review of Resident #22's Annual MDS dated [DATE] revealed in Section C - C0500, BIMS Summary Score, a BIMS score of 13 (cognitively intact). Review of Resident #22's Comprehensive Care Plan initiated 08/09/2024 and reviewed/revised 11/11/2024 revealed the following focused areas: *Cognitive Impairment: Resident has impaired cognition and is at risk for a further decline in cognitive and functional abilities related to: dementia. An Intervention for the focus on cognitive impairment included Monitor/document/report to physician any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status changes. *Resident #1 has a diagnosis of depression as evidenced by tearfulness, change of appetite, and 675350 Page 15 of 23 675350 02/27/2025 Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605

F 0712 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some decreased social interaction. An intervention for the focus on her depression included Administer medications as ordered. Monitor/document for side effects and effectiveness. Arrange for psych consult, follow up as indicated. Discuss with the resident/family/caregivers any concerns, fears, issues regarding health or other subjects. Monitor/record/report to MD prn risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment, or safety awareness. *Diabetes: Resident has a diagnosis of diabetes and is at risk for unstable blood sugars and abnormal lab results. An Intervention for the focus on her diabetes included: Administer diabetic medications as ordered by the physician. Monitor for adverse reactions and report abnormals as detected. Provide therapeutic diet as ordered. Monitor blood Sugar as ordered by physician. Administer sliding scale insulin if ordered. For any blood sugars not within the acceptable parameters as dictated by the physician, document and notify the physician. Monitor for signs and symptoms of hypoglycemia such as: diaphoresis, dizziness, headache, confusion, hunger, irritability, pallor, tachycardia, slurred speech, tremor, lack of coordination, and staggering gait. Document and report to physician as needed. Monitor for signs and symptoms of hyperglycemia such as: Reduced appetite, increased thirst, urinary frequency, weight loss, fatigue, nausea, vomiting, dry skin, muscle cramps, Kussmaul breathing (deep and labored breathing), acetone breath (smells fruity), stupor, and coma. Document and report to the physician as needed. Review of Resident #22's Physician/NP/PA Progress Note reviewed on 02/28/2025 revealed: Created By NP and Revised By NP revealed there was no physician visits noted. Resident #23 Review of Resident #23's Face Sheet revealed a [AGE] year-old female initially admitted on [DATE] with a recent admission date of 11/28/2024. Resident #23's medical diagnoses included muscle weakness, insomnia, edema (swelling), urinary tract infection, dependent on renal dialysis, mild dementia, diabetes, and lack of coordination. Review of Resident #23's Annual MDS dated [DATE] revealed in Section C - C0500, BIMS Summary Score, a BIMS score of 13 (cognitively intact). Review of Resident #23's Comprehensive Care Plan initiated 04/18/2018 and reviewed/revised12/27/2023 revealed the following focused areas: *Falls: Resident has the potential for falls related to cognitive impairment, antihypertensive drug use, Psychoactive drug use, Gait/balance problems, Fall Risk Score >10 and night terrors. An Intervention for the focus on falls included using an Alarm when in bed due to poor safety awareness, *Fall Risk Screening upon admission and quarterly to identify risk factors, An intervention was to Keep bed in lowest position when not providing care. Review of Resident #23's Physician/NP/PA Progress Note reviewed on 02/28/2025 revealed: Created By NP, and Revised By NP 675350 Page 16 of 23 675350 02/27/2025 Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605

F 0712 revealed there was no physician visits noted. Level of Harm - Minimal harm or potential for actual harm Resident #50 Residents Affected - Some Review of Resident #50's Face Sheet revealed a [AGE] year-old female initially admitted on [DATE] with a recent admission date of 09/04/2024. Resident #50's medical diagnoses included: need for assistance with personal care, Cognitive communication deficit, dementia, psychotic disturbance, mood disturbance and anxiety disorder. Review of Resident #50's Annual MDS dated [DATE] revealed in Section C - C0500, BIMS Summary Score, a BIMS score of 00 indicating the resident was unable to complete the interview. Review of Resident #50's Comprehensive Care Plan initiated 09/09/2024 and revised on 10/08/2024 revealed the following focused areas: *Behavioral Problem: Resident has a behavior problem as evidenced by agitation and yelling at others. An intervention for the focus on behavioral problems included using an Intervene as necessary to protect the rights and safety of others, remove resident to an alternate location when needed to protect the rights and safety of others by offering to sit outside or activity in room. *Wandering/exit Seeking: Resident wanders related to cognitive impairment and is at risk for injury related to: Dementia. An intervention for the focus on wandering/exit seeking included: Attempt to determine any pattern or cause of wandering, reassure resident when distressed over placement, mark room door with a familiar object, to remember room location as indicated. *Secured Unit: Resident resides in a secured unit related to cognitive impairment/elopement risk secondary to Dementia Date initiated 06/27/2024, with a revision date 10/08/2024. An intervention for the focus on behavioral problems included, Monitor for adjustment to a new environment. Place resident within the facility according to their cognitive and functional abilities. Review of Resident #50's Physician/NP/PA Progress Note reviewed on 02/28/2025 revealed: Created By NP and Revised By NP revealed there was no physician visits noted . During an interview on 02/27/2025 at 8:44 AM, the RNC stated the facility could not provide any further physician visits due to we don't have them, they are not there. She stated the Medical Records staff along with the DON monitored resident physician visits. The RNC stated the failure to do so was missing personnel which had changed 5 times in the past year. She stated her expectations were for the NP to visit residents every 60 days and the MD every 30 days for the 1st 30 days of admission. She stated there could have been a negative impact on residents and potentially not receive the medical care they needed. During an interview on 02/27/2025 at 9:00 PM, the DON stated the procedures for physician visits were for them to see residents at least every 120 days. She stated she felt the facility would be getting a new medical director. The DON stated Medical Records, and the MDS nurse monitored physician visits. She stated the MDS had only been employed at the facility for about 6 weeks, and they were using a sister facility as a backup for visits. She stated since the MDS nurse had been hired they had not gone over the physician visits. The DON stated the possible negative impact to the residents were that the NP could have possibly not caught something that needed more knowledge. She stated the failure occurred with the change of staff. The DON stated her expectations were for the Doctor to see 675350 Page 17 of 23 675350 02/27/2025 Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605

F 0712 residents as per protocol. Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy Physician Visits with date implemented of 10/24/2022 revealed: Residents Affected - Some Policy it is the policy of this facility to ensure the physician takes an active role in supervising the care of residents. Policy Explanation and Compliance Guidelines: 1. The Medical Records staff/designee should: a. Track due dates of physician visits. b. Gather medical records and other documents for review by the physician during the visit. c. Provide records such as weight and vital sign records, accident reports, risk assessments, etc. for physician review. d. Remind the physician to date and sign all orders and write a progress note. e. Review the medical record for completeness, prior to the physician leaving the facility. f. Inform the Director of Nursing when a physician visit does not occur within the required timeframes. (Note: A physician visit is considered timely if it occurs no later than 10 days after the date the visit was required.) 2. The Physician should: a. New/readmission are preferably seen within 2 to 7 days of admission to the facility. 675350 Page 18 of 23 675350 02/27/2025 Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605

F 0712 b. Level of Harm - Minimal harm or potential for actual harm See resident within 30 days of initial admission to the facility. c. Residents Affected - Some The resident must be seen at least once every 30 calendar days for the first 90 days after admission . .i. At the option of the physician, required visits in SNF 's, after the initial visit, may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist that is acting within scope of practice defined by state law and under the supervision of the physician. 675350 Page 19 of 23 675350 02/27/2025 Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605

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 observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in permanently affixed compartments during medication storage inspection for 1 (cart #1) of 5 medication carts reviewed for storage. The facility failed to ensure medication cart #1 was locked and secured while unattended. This failure could result in a drug diversion. The findings included: During an observation on 02/25/25 at 5:05 PM medication cart #1 was sitting against the wall with the drawers facing outwards unattended and unlocked. The button that locked on the medication cart was not pushed in and the drawer could open when pulled. There were no staff seen on the halls. RN A came walking up the hall. She stated the medication cart should not have been left unlocked and unattended. RN A stated the nurse responsible for the cart was RN B. RN A stated RN B was in the dining room assisting residents with their meals. RN A locked the medication cart #1 . During an interview on 02/26/2025 at 06:52 PM the DON stated her expectation was that the medication carts should have been locked. The nurse assigned to the medication cart was responsible for locking and monitoring the medication cart while doing rounds at the facility. The possible effect on residents was they could take the wrong medication, and this could make them sick or cause death. The DON stated the failure was due to the nurse got distracted, walked away, and forgot to lock the medication cart. During an interview on 02/27/2025 at 04:09 PM RN B stated the medications carts should be locked when not in use. RN B stated a resident could take a medication that was not prescribed for them and have a reaction or even cause death. RN B stated she just got busy and forgot to lock the medication cart. RN B stated types of medications on the cart were cardiac medications, blood pressure medications, over the counter medications, stool softeners, vitamins, eye drops, and inhalers but no insulin. RN B stated she had been trained to keep the medication carts locked when not in use. Review of the facility's policy titled: Medication Storage date revised 01/02/2024 revealed: It is the policy of this facility to ensure all medications housed on our premises will be stored, dated, and labeled according to manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. 675350 Page 20 of 23 675350 02/27/2025 Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605

F 0761 b. Level of Harm - Minimal harm or potential for actual harm Only authorized personnel will have access to the keys to locked compartments. c. Residents Affected - Few During a medication pass, medications must be under the direct observation oof the person administering medications or locked in the medication storage area/cart 675350 Page 21 of 23 675350 02/27/2025 Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record review 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. 1. Hair net was not used for the DA, while he entered the kitchen. 2. Hand hygiene was not performed by CNA-C and the AD while passing trays in the hallway. These failures could place residents that eat out of the kitchen at risk for contamination and food borne illnesses. Findings included: During an observation on 02/24/2025 beginning at 10:30 AM the facility kitchen revealed: 1. The DA entered through the back entrance door, walked through the kitchen, and out the front door of the kitchen with no beard cover on. 2. Hand hygiene was not used during the passing of trays in the hallways for CNA-C and the AD. During an interview on 2/24/2025 at 12:05 PM CNA-C on the MCU failed to perform hand hygiene when serving and setting up food between residents. CNA-C was also observed leaving the MCU to go to kitchen to get silverware for a resident. When she returned, she gave the residents her silverware and proceeded to get another tray without performing hand hygiene. CNA-C stated she should have performed hand hygiene and did not have a reason as to why she did not . During an interview on 02/24/2025 at 3:23 PM, the DM stated the DA should have stopped at the back door prior to entering the kitchen and placed a beard restraint on. She stated the DM monitored her dietary staff for hygiene practices. The DM stated once the trays arrived on the hallways, the DON should have been responsible for her staff and their trainings. She stated the negative impact for residents could have been cross contamination which could have allowed residents to have infections. The DM stated the failure occurred with staff not having followed IC practices as they were trained. She stated her expectations for the passing of trays, were the staff should have used hand hygiene between passing trays to each resident. During an interview on 02/24/2025 at 3:36 PM, the DA stated he should have placed a beard restraint on prior to having walked through the kitchen. He stated he had not done so, due to being in a hurry. He stated it could have caused hair in food and/or cross contamination. 675350 Page 22 of 23 675350 02/27/2025 Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 02/25/2025 at 4:00 PM the Activities Director stated she was new to the facility and started January 27th of this year. She stated she was told after passing trays to residents that she needed to perform hand hygiene between residents. She stated she had not taken her IC trainings concerning hand hygiene. She stated in not doing so, she could have contaminated residents if sick or possibly have caused cross contamination between residents. The AD stated she was working on her food handler's certification and had not received it at that time of the interview. During an interview on 02/27/2025 at 8:50 AM, the DON stated that the staff that passed trays should hand sanitize their hands between each resident, and that staff should have worn hair restraints while inside the kitchen. She stated she was responsible for monitoring staff and hygiene once the food went to the floor and passing out the trays to residents. The DON stated the negative impact to residents in not doing so would be hair in their food, infection control, and contamination of the resident food. She stated the failure occurred with the staff getting in a hurry. The DON stated her expectations were for staff to slow down and do what they were taught. Record Review of the facility's policy Food Safety and Sanitation Plan with a review date 07/22/2021 revealed: Policy: It is the policy of this facility to follow an effective, proactive food safety program that is based on preventing food safety hazards before they occur. The Hazard Analysis Critical Control Point (HACCP) Plan is an example of such a program. Fundamental Information: HACCP, is a food safety plan designed to prevent the outbreak of foodborne illness. It ensures safe food handling practices from food procurement through food service. While all steps in the handling of food are important, specific steps have been identified as critical in preventing food borne illness. HACCP requires food handling at each critical point. Some operational steps that are critical to control in facilities to prevent or eliminate food safety hazards are thawing, cooking, cooling, holding, reheating of foods, and employee hygienic practices. Corrective actions are built in to the system for implementation when improper procedures are discovered through monitoring. HACCP is not an exact science, but rather a tool for creating a better understanding and awareness of the potential for foodborne bacterial contamination of food and how to best control this in a food service operation. Nursing home residents risk serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices present a potential source of pathogen exposure for residents. Sanitary conditions must be present in health care food service settings to promote safe food handling. Review of the FDA Food Code 2022 FDA Food Code 2022: Full Document accessed 02/27/2025 revealed: 2-402.11 Effectiveness. (Hair Restraints) 1. Code of Federal Regulations, Title 21, Sections 110.10 Personnel. (b) (1) Wearing outer garments suitable to the operation (4) Removing all unsecured jewelry (6) Wearing, where appropriate, in an effective manner, hair nets, head bands, caps, beard covers, or other effective hair restraints. (8) Confining .eating food, chewing gum, drinking beverages or using tobacco and (9) Taking other necessary precautions 675350 Page 23 of 23