Health inspection·July 10, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review the facility failed to ensure all alleged violations involving neglect were reported to the State Survey Agency in a timely manner for 1 of 5 (Resident #) residents reviewed for abuse and neglect. The facility failed to report an incident to the state survey agency when Resident #1 had a choking episode while eating, resulting in death, after staff failed to activate 911 emergency response on 06/13/2025. The failure could place residents at risk of physical harm, pain, mental anguish, or death. Findings included:Record review of Resident #1's clinical resident profile reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of diabetes type 2 (elevated blood sugar), vascular dementia (difficulty thinking and processing thoughts), major depressive disorder, and anxiety.Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS of 11, which indicating mild cognitive impairment. It also indicated Resident #1 did not have any swallowing disorders such as holding food in his mouth, coughing, or choking during meals or difficulty or pain with swallowing. Record review of Resident #1's care plan dated 01/17/2024 reflected: Receives Therapeutic and Mechanically soft Diet, Resident has decreased appetite with poor meal intake at times. Interventions included: Assist resident with meals as needed. Set up meal tray, open beverages, cut foods, provide assistance as needed.Record review of Resident #1's progress notes dated 06/13/2025 reflected At approximately 5:20, PM CNA heard calling out for help. This nurse entered Dining room and noted resident gasping and coughing. CNA stated that resident was eating dinner and began choking on his food. Noted mech soft dinner tray in front of resident, consistent with resident's diet orders. This nurse assessed Resident's mouth and noted food in airway. Finger sweep attempted while visualizing food without success. This nurse started abdominal thrusts and sent CNA to alert another nurse for additional assistance. LVN B arrived, and this nurse and attempted abdominal thrusts several more times without success. Resident's respirations ceased and pulse was unobtainable. Code status confirmed as DNR. No signs of life noted. Notified PCP, RP, and DON. Signed by LVN A In an interview on 07/08/2025 at 1:00 pm, the VA Nurse stated she reviewed the incident at her monthly visit to monitor the VA contract residents that reside at the nursing facility. She stated she asked the facility DON why 911 was not notified. She stated the DON stated that the facility was honoring the residents DNR wishes. She stated that the facility's failure to activate emergency services by calling 911 during the choking episode, was a reportable incident. The VA nurse stated that Resident #1 having a DNR on file did not mean that the facility should not treat him if he was choking. She stated the ADM and DON told her it was not reportable because they were aware of the incident, and it was not under suspicious circumstances that followed their policy. In an interview on 07/09/2025 at 3:15 pm, the DON stated she was the back up for reporting significant events to state when the ADM was out of the building. She stated the incident involving Resident #1 was not reported because it was not suspicious. She stated they knew exactly what happened. She Page 1 of 7 675525 675525 07/10/2025 Willow Park Rehabilitation Health Care Center 1000 Fm 3220 Clifton, TX 76634

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated she did not think it was neglectful that 911 was not called because it would not have changed the outcome. In an interview on 07/09/2025 at 3:47 pm, the ADM stated she was responsible for reporting incidents to the state if needed. She stated the incident involving Resident #1's death was not reportable because the facility knew the situation, there was no abuse or neglect, and they followed policy. She stated she did not know how to answer if not calling 911 was neglectful. Record review of the facility's policy titled Abuse Prohibition Policy reviewed 06/02/2025 reflected: The facility will report all allegations and substantiated occurrences of abuse, neglect or misappropriation of resident property to the state agency and to all other agencies as required by law and will take all necessary corrective actions depending on the results of the investigation. The Abuse Coordinator will report all allegations of abuse, neglect with serious bodily injury, mistreatment with serious bodily injury, exploitation with serious bodily injury, and injuries of unknown source with serious bodily injury immediately or within two hours of the allegation. 'The Abuse Coordinator will report all other allegations of neglect, mistreatment, exploitation, injuries of unknown source and misappropriation within 24 hours of the allegation.Record review of the facility's policy titled Resident Incident and Visitor Accident Report reviewed 10/08/2020, [DATE] and June 2024 reflected: The facility will conduct an investigation of all incidents involving residents of the facility. The facility will conduct an investigation of all non-resident accidents that occur on the property of the facility. The investigation will be conducted by designated personnel and reported to the Administrator/designee. Incidents/Accidents of Unknown Origin will be reported in accordance with state and federal regulations. 675525 Page 2 of 7 675525 07/10/2025 Willow Park Rehabilitation Health Care Center 1000 Fm 3220 Clifton, TX 76634

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 5 (Resident #1) residents reviewed for quality of care.The facility failed to activate 911 emergency services response on 06/13/2025 for Resident #1 when he had a choking episode while eating resulting in his death. An IJ (Immediate Jeopardy) was identified on 07/08/2025. The IJ template was provided to the facility on [DATE] at 5:12 PM. While the IJ was removed on 07/10/2025, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This failure could place residents at risk of physical harm, pain, mental anguish, or death. Findings included:Record review of Resident #1s clinical resident profile reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnosis of diabetes type 2 (elevated blood sugar), vascular dementia (difficulty thinking and processing thoughts), major depressive disorder, and anxiety.Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS of 11, which indicating mild cognitive impairment. It also indicated Resident #1 did not have any swallowing disorders such as holding food in his mouth, coughing, or choking during meals or difficulty or pain with swallowing. Record review of Resident #1's care plan dated 01/17/2024 reflected: Receives Therapeutic and Mechanically soft Diet, Resident has decreased appetite with poor meal intake at times. Interventions included: Assist resident with meals as needed. Set up meal tray, open beverages, cut foods, provide assistance as needed.Record review of Resident #1's progress notes dated 06/13/2025 reflected At approximately 1720, CNA heard calling out for help. This nurse entered Dining room and noted resident gasping and coughing. CNA stated that resident was eating dinner and began choking on his food. Noted mech soft dinner tray in front of resident, consistent with resident's diet orders. This nurse assessed Resident's mouth and noted food in airway. Finger sweep attempted while visualizing food without success. This nurse started abdominal thrusts and sent CNA to alert another nurse for additional assistance. LVN B arrived, and this nurse and attempted abdominal thrusts several more times without success. Resident's respirations ceased and pulse was unobtainable. Code status confirmed as DNR. No signs of life noted. Notified PCP, RP, and DON. Signed by LVN [NAME] an interview on 07/08/2025 at 1:00 pm, The VA Nurse stated she reviewed the incident at her monthly visit to monitor the VA contract residents that reside at the nursing facility. She asked the facility DON why 911 was not notified. She stated the DON stated that the facility was honoring the residents DNR wishes. She stated that the facilities failure to activate emergency services by calling 911 during the choking episode was a reportable incident. The VA nurse stated that Resident #1 having a DNR on file did not mean that the facility should not treat him if he was choking. The facility stated they followed their policy they did not call 911 because the resident did not lose consciousness until the very end of the choking episode and at that time he had no pulse. She stated the ADM and DON told her it was not reportable because they were aware of the incident, and it was not under suspicious circumstances that followed their policy. In an interview on 07/08/2025 at 1:46 pm, LVN A stated on 6/13/25 she was passing the dinner trays out to the residents on the secure unit when the CNA working with her started yelling for help. Resident #1 was choking so she did a mouth sweep and a visual check on his mouth. LVN A stated Resident #1 continued to choke so she began chest thrust and was unsuccessful. She sent the CNA to get assistance and 2 more LVNs came to attempt the chest thrust. The Choking episode all happened so quickly no one initiated a 911 call. She stated the resident went limp and no longer was Residents Affected - Few 675525 Page 3 of 7 675525 07/10/2025 Willow Park Rehabilitation Health Care Center 1000 Fm 3220 Clifton, TX 76634

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few breathing. LVN A stated the nurses checked his code status, and it as DNR. They called their supervisor who told them to honor the DNR. LVN A stated an RN later came and pronounced the resident's time of death at the facility. LVN A stated their policy stated if the resident was a DNR, they did not have to call 911. Normally if choking were to happen, they would call 911, but staff were trying to get his airway clear. The DON showed the policy to staff that stated if a resident actively passes during emergency treatment, and they had a DNR, the nurse did not have call 911 emergency services. LVN A stated negative effects for not having 911 emergency services dispatched during an emergency such as choking could be that the resident could die. In an interview on 07/08/2025 at 1:57 pm, LVN B stated he was called to the secure unit with a suction machine and responded to Resident #1's choking. He took the suction machine to the secure unit and began assisting with the Heimlich maneuver. LVN B stated he was doing the chest thrust, so he was not aware of anyone calling 911. Anyone who was present during an emergency, could dial 911 for emergency response. LVN B stated negative effects of not activating 911/an emergency response for resident during a choking episode, could be death.In an interview on 07/08/2025 at 2:03 pm, LVN C stated she was notified by another nurse to get a suction machine and come to the secure unit. They set up the suction machine and attempted chest thrust on Resident #1. LVN C stated she was not aware of anyone calling 911. Resident #1 did not lose consciousness until the very end before he passed away. LVN C stated it was the first time she had encountered a resident choking. LVN C stated the negative effects to a resident for not calling 911 in an emergency response, depended on the situation. If it were something the staff could take care of within the facility, they would not call 911. LVN C stated the facility was honoring the resident's wishes with his DNR.In an interview on 07/08/2025 at 2:21 pm, the DON stated it was her expectation that when a resident was choking, the staff should have assessed the resident, visualized the oral cavity, removed the object if they are able, and started the Heimlich. The DON stated staff should have activated 91l. She stated Resident #1 was a DNR, so they did not proceed with any other intervention after he became unresponsive. She had not educated staff on the choking policy in writing; it was verbalized only when they discussed the event. The DON stated the negative effects for not issuing a 911 emergency response when a resident was choking was that the patient could die.In an interview on 07/08/2025 at 2:26, The ADM stated if a resident was choking, she expected the staff to follow choking guidelines. This included calling 911. DNR did not mean do not treat. The ADM stated she addressed the issue in an in service on 6/18/2025 at an all-staff meeting.In an interview on 07/08/2025 at 3:00 PM, the Medical Director stated the facility should have activated 911 emergency services response when Resident #1 was choking, and nurses were unable to clear the airway. He stated just because there was a DNR, did not mean not to treat the resident. Resident #1 was a fast eater and did have a diagnosis of dysphagia. the Medical Director stated the negative effects for a resident for not initiating 911 in an emergency such as choking could be death.Record review of the facility's policy Titled Policy for Choking / Foreign Body Obstructing Airway dated August 2021 and updated 6/18/2025 reflected: 1. Stand behind the resident.2. Wrap your arms around the resident's waist.3. Make a fist with one hand.4. Place the thumb side of your fist against the resident's upper mid-abdomen, below the ribcage and above the navel.5. Grasp your clenched fist with your other hand.6. Press your fist into the resident's upper abdomen with a quick upward thrust.7. Do not squeeze the ribcage. Contain the force of the thrust to your hands.8. Repeat the thrusts until the foreign body is expelled or the resident loses consciousness.9. If the airway is cleared immediately, report to nursing administration, resident's Physician for follow up as needed.10. If the airway does not clear immediately, and the resident becomes unresponsive, activate medical emergency response (ex. Code blue, call 91 1) 675525 Page 4 of 7 675525 07/10/2025 Willow Park Rehabilitation Health Care Center 1000 Fm 3220 Clifton, TX 76634

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and continue to attempt to the airway of the unresponsive resident.11. If at any time the resident is assessed to have no pulse and no respirations, follow goals of the resident's code status to determine if CPR should be initiated.12. Continue CPR if indicated until Emergency Personnel assume care of resident.13. Complete incident report and notification of responsible party & MAn Immediate Jeopardy was identified on 07/08/2025 at 5:12 PM. and an IJ template was provided to the ADM and DON. A plan of removal was requested at that time.The following Plan of Removal, submitted by the facility, was accepted on 07/10/2025 at 12:58 PM. On 7/8/2025 an abbreviated survey was initiated at center. On 7/8/2025 the surveyor provided Immediate Jeopardy (IJ template provided) that the regulatory services have determined that the conditions at the facility constitute an immediate threat to residents' health and safety. Notification of Immediate Jeopardy states as follows Tag F689 based on observation interview and record review failed to provide adequate supervision and devices to prevent accidents for 1 (Resident #1) of 4 residents reviewed for accidents and supervision. The facility failed to ensure Resident #1 received 911 emergency services during a choking episode on 6/13/2025 at 5:20 PM. The resident expired at the facility. 1. Corrective Action Taken:On July 8, 2025, Corporate Clinical Specialist in serviced Administrator and ADON on facility's emergency response policy, including the requirement to call 911 during a choking incident regardless of DNR status. Competency verified by quiz, requiring 100% to pass.On July 8, 2025, Administrator and DON conducted a facility-wide in-service training regarding facility's emergency response policy, including the requirement to call 911 during a choking incident regardless of DNR status. Competency verified by quiz, requiring 100% to pass. No staff will be able to work until in-servicing and competency completed. This will be conducted to all staff and monitored by Administrator. Evidence will be kept in a binder in the administrator's office. On July 9, 2025, Corporate Clinical Specialist, in-serviced DON and ADON regarding proper performance of abdominal thrust or other measures during a choking incident. Competency verified by return demonstration and documented on the skills check off. This will be monitored by the Administrator. Evidence will be kept in a binder in the administrator's office. On July 9, 2025, DON and ADON in-serviced nursing staff regarding proper performance of abdominal thrust or other measures during a choking incident. Competency verified by return demonstration and documented on the skills check off. This will be monitored by the Administrator. Evidence will be kept in a binder in the administrator's office. 2. Identification of Other Residents: A review of all current residents with DNR orders was completed on July 8, 2025, to ensure that advanced directives are clearly documented in the medical record. Completed by CCS and ADON.No other residents were found to be at immediate risk.A review of all current residents with swallowing difficulties was completed on July 9, 2025, to ensure that care plans are clearly documented in the medical record. This review was conducted by the CCS and Director of Nursing (DON) No issues identified they were immediately corrected on 7/9/2025. 3. Systemic Changes: The facility's choking and emergency response policy was revised on 7/9/2025 by Regional Director of Operations in consultation with Corporate Nurse. The statement Repeat thrust until the foreign body is expelled or the resident loses consciousness was revised to Repeat the thrust until the foreign body is expelled. The statement if the airway does not clear immediately, and the resident becomes unresponsive, activate medical emergency response (ex. Code blue, call 911) and continue to attempt to clear the airway of the unresponsive resident was removed. The new revisions states that If the airway does not clear immediately activate medical emergency response and continue to attempt to clear the airway. On July 8, 2025, the Administrator and Director of Nursing conducted a facility-wide in-service training on the facility's emergency response policy. Staff were educated that during any choking incident, 911 must be called immediately once the Heimlich maneuver 675525 Page 5 of 7 675525 07/10/2025 Willow Park Rehabilitation Health Care Center 1000 Fm 3220 Clifton, TX 76634

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few is initiated, regardless of the resident's DNR status. Competency was verified through a mandatory quiz, with a required passing score of 100%. No employee will be permitted to work until both the in-service and competency have been successfully completed. This training will be provided to all staff and overseen by the Administrator. Documentation of completion and competency will be maintained in a binder located in the Administrator's office.All new hires will receive mandatory training by the DON, or designee, on emergency response protocols related to choking, incidents, and emergency responses during orientation. These drills will consist of Mock Drills with different choking-based scenarios.A competency quiz has been implemented to assess staff understanding of emergency procedures quarterly, requiring 100% to pass.CCS and DON are auditing diets to ensure correct completed 7/9/2025. 4. Monitoring and Quality Assurance: The Corporate Clinical Specialist educated the DON and ADON regarding emergency protocols and response.The Director of Nursing (DON) or designee will conduct random audits of staff knowledge and response by conducting medical emergency drills (i.e., choking episode) weekly for 8 weeks, then monthly for 4 months. Results of audits will be reviewed in the facility's Quality Assurance and Performance Improvement (QAPI) meetings.Any deficiencies will result in immediate re-education.Medical Director notified 7/9/2025, and reviewed Plan of Removal and approved. 5. Responsible Party: The Administrator and Director of Nursing are responsible for implementing and monitoring this Plan of Correction. 6. confirmed the facility implemented their plan of removal sufficiently to remove the IJ by:1. Record review of in-service education dated 07/08/2025 for the ADM, DON, ADON and all staff reflected they had been educated over the policy on choking/relief of foreign body obstructing the airway. Verified with 4 signatures. Education provided on always calling 911 in an emergency no matter what the DNR status of the resident is. Understanding was verified by receiving 100% on post education quiz. Verified with 73 signatures.2. Record review of an audit dated 07/08/2025 reflected all residents with DNR orders to ensure that advanced directives were clearly documented in the medical record had been completed. Record review of an audit dated 07/08/2025 reflected A review of all current residents with swallowing difficulties was completed on July 9, 2025, to ensure that care plans are clearly documented in the medical record. This review was verified by an audit of 5 random residents medical records. The medical records reflected DNR / advanced directives were clearly documented and diet orders were correct. Medical record review of care plans reflected that resident with swallowing difficulties had interventions within the care plan. 3. Record review the facility's Choking and Emergency Response Policy was revised on 7/9/2025 by Regional Director of Operations in consultation with Corporate Nurse and again on 07/10/2025. The statement Repeat thrust until the foreign body is expelled or the resident loses consciousness was revised to Repeat the thrust until the foreign body is expelled. The statement if the airway does not clear immediately, and the resident becomes unresponsive, activate medical emergency response (ex. Code blue, call 911) and continue to attempt to clear the airway of the unresponsive resident was removed. The new revisions states that If the airway does not clear immediately activate medical emergency response and continue to attempt to clear the airway. On July 10, 2025, the Administrator and Director of Nursing conducted a facility-wide in-service training on the facility's emergency response policy. To clarify the policy revision, the facility contacted each employee and instructed them on the policy revision. Verified through sign-in sheet with 73 signatures and DON and ADM interview. 4. Record review of QAPI meeting held on 07/08/25 at 5:15pm revealed the meeting was attended by the Medical Director, Administrator, and DON.Interviews conducted on 07/10/2025 between 1:45 pm - 2:45 pm CNA C, CNA D, CNA E, CNA F, CNA G, MA H, CNA I, CNA J, Social Worker, LVN K, CNA L, LVN M, LVN N, LNV O, RN 675525 Page 6 of 7 675525 07/10/2025 Willow Park Rehabilitation Health Care Center 1000 Fm 3220 Clifton, TX 76634

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few P, Business Office Manager, Activities Director, Activities assistant Director, Housekeeper, Dietary cook, Dietary Manager, and Laundry Supervisor, revealed that all verbalized if a resident were to have a choking episode, 911 emergency response should be activated. They stated that any staff member could dial 911. They stated they did not wait for a resident to become unconscious prior to calling 911. They stated 911 should be activated immediately if chocking was not cleared with coughing. They were able to demonstrate the chest thrust to dislodge objects obstructing the airway. The staff stated DNR did not mean do not treat. On 07/10/2025 at 3:04 pm, the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a level of no actual harm with the potential for more than minimal harm with a scope identified as isolated due to the facility's need to monitor the implementation and effectiveness of its POR. 675525 Page 7 of 7