Health inspection·July 27, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for four (Resident #27, #30, #33, and #215, ) of 44 residents observed for wheelchairs. The facility failed to properly maintain wheelchairs for Residents #27, #30, #33, and #215. The wheelchair arm rest pads were torn and cracked with exposed interior foam. The arm rest pads could not appropriately be cleaned due to the cracked and exposed foam. This failure could place residents at risk for diminished quality of life and at risk for skin issues and discomfort due to the lack of a well-kept wheelchairs. Findings included: 1.Review of Resident #27's admission MDS assessment, dated 05/31/2023, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with the following diagnoses: cerebral infarction, lack of coordination, and muscle weakness, hemiplegia, and hemiparesis on the right dominate side. Mobility indicated the use of a wheelchair. Resident #27 was severely impaired for decision making. Review of Resident #27's plan of care dated 07/05/2023 with updates reflected goals and approaches to include wheelchair mobility. An observation on 07/26/2023 at 12:15 p.m., revealed Resident #27's right side arm rest on the wheelchair was cracked with jagged edges, and the interior padding was exposed. The arm pads were not appropriately cleaned. 2.Review of Resident #30's quarterly MDS assessment, dated 06/30/2023, reflected she was an [AGE] year-old female admitted to the facility on [DATE], with the following diagnoses: dementia, performance deficit, and muscle weakness and lack of coordination. Mobility was coded for wheelchair usage. Resident #10's was cognitively intact. Review of Resident #30's plan of care dated 06/30/23 with updates reflected goals and approaches to include wheelchair mobility. An observation on 07/26/23 at 12:12 p.m., revealed Resident #30's right arm rest was cracked with jagged edges on the wheelchair with the interior padding exposed. The arm pads were not appropriately cleaned. Page 1 of 6 675525 675525 07/27/2023 Willow Park Rehabilitation Health Care Center 1000 Fm 3220 Clifton, TX 76634

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. Review of Resident #33's quarterly MDS assessment, dated 07/02/2023, reflected she was an [AGE] year-old female admitted to the facility on [DATE], with the following diagnosis: Alzheimer's, and depression. Resident was coded for wheelchair mobility. Resident was severely impaired or decision making. Review of Resident #33's plan of care dated 07/06/2023 with updates reflected goals and approaches to include wheelchair mobility. An observation on 07/26/23 at 11:05 a.m., revealed Resident #33's right arm rest was cracked with jagged edges on the wheelchair with the interior padding exposed. The arm pads were not appropriately cleaned. 4. Review of Resident #215's admission MDS assessment, dated in progress, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with the following diagnoses: difficulty in walking, lack of coordination, and metabolic encephalopathy. He was coded for wheelchair mobility. Resident #215 was severely impaired for decision making. Review of Resident #215's plan of care dated in progress reflected goals and approaches to include wheelchair mobility. An observation and interview on 07/26/2023 at 1:20 p.m., revealed Resident #215's right side and left side arm rest on the wheelchair was cracked with jagged edges, and the interior padding was exposed. The arm pads were not appropriately clean, they were stained with a dark substance. Resident #215 stated that his wheelchair could have better arms on it. Interview on 07/26/2023 at 11:18 a.m., the Administrator revealed that the residents did require wheelchairs that were in good repair, and she knew that if the resident did not it could affect their ability to have mobility. The Administration stated that the staff were supposed to report to her, and she would make sure the parts were ordered, then the maintenance man would repair the wheelchairs. The Administrator stated that the restorative aide were supposed to be making rounds and checking the wheelchairs weekly and reporting back to her. Interview on 07/26/2023 at 10:45 a.m., LVN A revealed if something was broken or needed to be repaired, like a wheelchair he would just tell the maintenance man. LVN A stated the maintenance man was usually there and if he was not then he would tell the DON or ADON about the need of repair. LVN A stated that there was no logbook to document in for maintenance repairs and there was no communication system for repairs. The LVN stated the maintenance man repaired the wheelchairs, but there was also a company that could repair the wheelchairs also. LVN A was not aware of who the company was or how to contact them. LVN A was not aware of any wheelchairs requiring repair. Interview on 07/26/2023 at 12:20 p.m., the Maintenance Man revealed, if there was a piece of equipment, like a wheelchair that required repair, he would report it to the administrator, and she will order the parts. The Maintenance Man stated if he had the parts he would repair it. The maintenance man said there was a logbook at the nurse's station that he checked each day, that the staff were supposed to communicate in, but most of the staff just tells him. The Maintenance man stated that there was a specialty company that does come and work on the specialty wheelchairs that had been provided to certain residents, I will call them if the administrator or staff tell me about needed repair. The maintenance man stated the staff knew to place a note on the wheelchairs that need repair and remove the wheelchair from use. 675525 Page 2 of 6 675525 07/27/2023 Willow Park Rehabilitation Health Care Center 1000 Fm 3220 Clifton, TX 76634

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 07/26/2023 at 1:24 p.m., CNA B revealed if something was broken, she would tell the maintenance director or the nurse. CNA B said she was not aware of any place to document the need for something to be repaired if was broken. CNA B sated she was not aware of any wheelchairs that required repair. Interview on 07/26/2023 at 2:13 p.m., the DON revealed the facility staff was supposed to report to the maintenance man about any repairs needed to wheelchair and put a note on the wheelchair and remove it from use right away. The DON was unaware if there was a log at the nurse's station. The DON stated she was not aware of any wheelchairs that needed repair. Interview on 07/27/23 at 9:57 a.m., the Restorative Aide revealed she was just told on yesterday (07/26/2023) by the Administrator, she was to check wheelchairs weekly for wear and tear and report to the Administrator or the DON if the wheelchair required repair. The Restorative Aide stated she was not doing this before. At the time of exit on 07/27/23 at 12:45 p.m. there was no policy and procedure for Assistive Devices and Equipment for the facility, as stated by the Administrator. 675525 Page 3 of 6 675525 07/27/2023 Willow Park Rehabilitation Health Care Center 1000 Fm 3220 Clifton, TX 76634

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure Nurse Staffing Information was posted daily for one of one building. Residents Affected - Some The facility did not post and maintain the required staffing information from July 21, 2023, to July 24, 2023. This failure could place residents and visitors at risk of not knowing how many nursing staff were on duty and the actual hours worked per shift daily. Findings include: During an observation on 07/24/23 at 06:18 PM, Nursing Staffing Information dated 07/21/23 was posted up in the facility main entrance visible to all residents and visitors. In an interview on 07/24/23 at 6:42 PM, DON revealed the Nursing Staffing Information should have been posted by the weekend RN supervisor during the weekends in the morning, and at the beginning of every shift. DON stated, if we have any change in the census or staff call-in, I will modify the nursing staffing sheets as needed. This would be completed in the morning when I come to work. DON stated, during the week I check it, on the weekends the weekend supervisor is responsible for the Nursing Staffing Information. DON confirmed that the updated staffing sheet was placed in the morning slightly after the survey team had arrived. The DON stated, t he staffing sheets were not done for this weekend, because my weekend supervisor simply forgot to advance the sheets. Hours should be posted so that both family members and residents are aware of how many staff might be in the building at during each shift. Without that information, residents and visitors may feel that there are not enough staff or if all staff is busy at the time that there are no staff in the building. In an interview on 7/27/23 at 1:09 PM with DON and Administrator they stated they did not have a policy for Nursing Staffing Information/Postings, and no policy was produced before the end of the survey. 675525 Page 4 of 6 675525 07/27/2023 Willow Park Rehabilitation Health Care Center 1000 Fm 3220 Clifton, TX 76634

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to maintain an effective pest control program for 1 of 1 facility reviewed for pests in that: Residents Affected - Some Flies were observed in multiple areas of the facility. This failure could affect residents by placing them at an increased risk of exposure to pests and vector-borne diseases and infections. Findings included: Observation on 07/24/23 at 6:40 PM revealed a fly crawling across the nurse's station. Observation on 07/24/23 at 6:45 PM revealed a fly was flying on Hall D. Observation and interview on 07/24/23 at 6:55 PM revealed a fly crawling on the medication cart on Hall D. Interview with LVN C revealed that this time of the year was bad for flies. The LVN stated she did see the pest control man at the facility. She said that Administrator handles all of that. Observation on 07/24/23 at 7:05 PM revealed a fly crawling on the table in the conference room. Observation on 07/25/23 at 11:12 AM revealed a fly flying around a tray of food at the nurse's station. Observation on 07/25/23 at 12:17 PM revealed a fly crawling on the upper arm of a unidentified resident. The resident swatted at the fly, the fly began to crawl on the table, the resident did not notice the fly. The resident could not comment when ask about the fly. Further observation revealed files on three different tables while food was being served. Observation and interview on 07/25/23 at 12:18 PM revealed a fly flying around Resident #14's head. Resident #14 said she cannot swat at the fly, and she tells the staff to swat at them. Resident #14 said at this time of the year they were worse, but they were so aggravating. Resident #14 stated that she did see the pest control people there, but they still had flies. Observation on 07/25/23 at 1:10 PM revealed a fly crawling on the medication cart at the nurse's station. Observation on 07/25/23 at 2:20 PM revealed three flies flying down Hall A, one of the flies landed on the door frame of a resident's room. In a confidential group meeting of five residents on 07/26/23 at 10:30 a.m. revealed that the residents stated the flies were a problem, especially when they were in the dining room, crawling and flying around, that was dirty. The residents stated they did see the pest control company there. An interview on 07/26/25 at 1:04 PM with the Maintenance Man revealed that the pest control company came one time a month. The maintenance man stated there had been flies in the facility, he thought it was related to the season. He stated there was a special blue light at the smoking area entrance and at the front door, those were supposed to attract flies. The Maintenance Man stated he sprays at 675525 Page 5 of 6 675525 07/27/2023 Willow Park Rehabilitation Health Care Center 1000 Fm 3220 Clifton, TX 76634

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the front windows outside himself because he sees flies gathering out there. He said if the staff observes any pest int the facility they can write it in the pest control book the nurses station, I check that book every day. Observation and interview on 07/26/23 at 1:12 PM revealed no pest control logbook at the nurse's station. LVN A stated she was unaware of any pest control logbook, she had never seen one, if she saw pest, she would tell the Maintenance man. In an interview on 07/26/23at 1:45 PM with DON revealed she had not seen any flies, she but if she did, she would tell the maintenance man so that he could call the pest control company. In an interview on 07/26/23 at 3:40 PM, the Administrator stated the monthly visits include flies, and that she assumed the pest control contract covered flies. The Administrator stated the maintenance man would have the documentation of what {pest control company} sprays for in the contract. When asked about the outcome for the residents administrator stated, flies do carry disease and it is an infection problem, she was unaware that the residents were complaining. The Administrator stated she was calling the [pest control company] right now and tell them to get out there today. Record review of the facility provided pest control log revealed, in part, dates and treatments as follows: Treatment dates and services performed: 7-23-2023 - performed an inspection on the interior and exterior of all areas, replaced fly light bulbs in activity room, refreshed all fly light glue boards 5-13-2023 - applied a fly baiting to entryways around facility and along top of walls, refreshed fly lights and glue boards in kitchen and activity room 5-3-2023 - performed an inspection of all areas; refreshed fly lights and blue boards Species listed in treatment: Flies, fruit flies, crickets, mice . Record review of the facility's policy Pest Control dated December 2020 reflected this facility maintains a current pest control contract at all times to ensure that the facility and grounds are free of nuisance, harmful insects . Review of the facility's pest control policy, dated April 2019, reflected, The facility maintains an effective pest control program . an ongoing pest control program to ensure the building and grounds are kept free of insects, and rodents. 675525 Page 6 of 6