Health inspection·October 16, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the ADL documentation for 9/15/23 to 10/15/23 did not record urine output for Resident #1. The ADL documentation indicated Resident #1 was totally dependent on staff for the management of her indwelling catheter but did not document the number of occurrences the catheter was emptied nor did it document urine volume emptied form the catheter. Record review of Resident #1's nursing progress notes dated 9/1/23 to 10/15/23 did not record urine output for Resident #1. Neither the number of occurrences the catheter was emptied nor urine volume emptied from the catheter were documented in the nursing progress notes from 9/1/23 to 10/15/23. During an interview on 10/16/23 at 11:00 a.m., CNA B said she had worked at the facility since November 2022. CNA B indicated she regularly took care of Resident #1 on the 6:00 a.m. to 2:00 p.m. shift. CNA B said CNAs did not document the volume of urine when they emptied catheters. CNA B said she would empty Resident #1's catheter and dump the urine in the toilet. CNA B said there was no place in the EMR documentation system to record that the catheter had been emptied or to enter a number (volume of urine). CNA B said she would notify the nurse if there had been no urine or decreased urine during her shift but otherwise would not notify the nurse regarding urine output. During an interview on 10/16/23 at 11:21 a.m., CNA C said she had worked at the facility since August 2023. CNA C said she had taken care of Resident #1 several times. CNA C said there was no place in the EMR documentation system to record that the catheter had been emptied or to enter a number (volume of urine). CNA C said when she emptied a resident's catheter, she would report the cc's (cubic centimeter is a commonly used unit of volume) to the nurse at the end of the shift. During an interview on 10/16/23 at 11:30 a.m., LVN A said she regularly took care of Resident #1 on the 6:00 a.m. to 6:00 p.m. shift. LVN A said the facility did not record urine volume. LVN A said the CNAs do not report anything to the nurses regarding urine output (number of times catheter was emptied or volume of urine) unless the urine volume was very low. LVN A said very low meant less than 100 ml (milliliters). LVN A said she would look at urine volume during her rounds but said just looking at the bags at any given time was not necessarily an accurate reflection because the last time the catheter bag had been emptied would be unknown. LVN A said she was not aware of any place on the EMR where CNAs could record the date and time the catheter bag had been emptied. LVN A said it was important to monitor urine output as decreased urine output could signal several issues such as obstruction, dehydration, or decreased kidney function. During an interview on 10/16/23 at 11:49 a.m., LVN E said she regularly took care of Resident #1 on the 6pm-6am shift. LVN E said she expected CNAs to notify her if Resident #1's urine volume was low. LVN E said she would look at urine volume in catheter bags during her initial rounds but could not say when the catheter bag was previously emptied. LVN E said she was not aware of any place on the EMR where CNAs could record the date and time the catheter bag had been emptied. During an interview on 10/16/23 at 12:12 p.m., LVN F said she regularly cared for Resident #1 on 6:00 a.m. to 6:00 p.m., shift. LVN F said he expected CNAs to notify him if a resident's urine appeared cloudy, bloody or had a foul odor when they (CNAs) emptied catheters bags. LVN F said the CNAs did not report volume of urine or when they emptied the catheter bag. LVN F said as far as he knew CNAs were not required to notify him of volume of urine or when they emptied the catheter bag. LVN F said he was not aware of any place on the EMR where CNAs could record the date and time the catheter bag had been emptied. During an interview on 10/16/23 at 3:30 p.m., ADON G said it was not the facilities policy to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676007 If continuation sheet Page 2 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676007 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Rehab & Nursing 1901 Whippoorwill Kilgore, TX 75662 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few record urine volume. ADON G said she did expect CNAs to monitor urine output and report to the nurse. ADON G said she did not think there was a place in the EMR for nurse aides to document urine output. During an interview on 10/16/23 at 3:34 p.m., ADON H said currently the facility did not have a DON and the corporate RN was filling in. ADON H said it was not the facilities policy to record urine volume. ADON H said she did expect CNAs and nurses to monitor urine output. ADON H said there was not a place in the EMR for nurse aides to document emptying catheters. ADON H said there was no system in place to ensure CNAs and nurses were monitoring urine output in residents with catheters. During an interview on 10/16/23 at 4:00 p.m., the Administrator said he expected staff to implement care plan interventions. The facility policy and procedure titled Indwelling Foley Catheter Guidelines dated 5/23/2014 stated The facility shall identify and assess patients with an indwelling catheter or at risk for catheterization, provide appropriate treatment and services to prevent urinary tract infections . The facility policy and procedure did not specifically address monitoring urine output in catheterized residents but did state .(if) occlusion (occurs) replace the catheter .maintain unobstructed flow .empty the collecting bag regularly . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676007 If continuation sheet Page 3 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676007 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Rehab & Nursing 1901 Whippoorwill Kilgore, TX 75662 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for 1 of 3 residents (Resident #1) reviewed for pain management. Residents Affected - Some The facility failed to perform and document a pain assessment with the administration of Resident #1's prn (as needed) pain medication. The facility failed to perform a follow up pain assessment after administering Resident #1's prn pain medication. This failure could place residents at risk for incomplete pain relief, discomfort and decreased quality of life. Findings Included: Record review of the physician order summary report dated 10/5/23 indicated she re-admitted to the facility on [DATE] with diagnoses including history of bladder cancer, breast cancer, high blood pressure, heart failure, presence of vascular implants and grafts, chronic embolism(blockage in an artery, caused by a foreign body, such as a blood clot) and thrombosis (formation of a blood clot (partial or complete blockage) within blood vessels, whether venous or arterial) of deep veins to both lower extremities, history of gastrointestinal hemorrhage, presence of ileostomy (a stoma surgically constructed by bringing the end or loop of small intestine out onto the surface of the skin) morbid (severe) obesity, Stage 2 chronic kidney disease (stages if kidney disorder range from Stage 1 [mild] to Stage 5 [most severe]), history of acute kidney failure, history of acute cystitis(inflammation of the bladder, usually caused by a bladder infection), and neuromuscular dysfunction of the bladder. Record review of the MDS dated [DATE] indicated Resident #1 made herself understood and usually understood others. The MDS indicated she had intact cognition, (BIMS of 13). The MDS indicated she was totally dependent on staff for bed mobility, dressing, personal hygiene, and bathing. The MDS indicated she required extensive assistance with toilet use. The MDS indicated transfers and locomotion in her wheelchair had only occurred once or twice during the 7 day look back period. The MDS indicated Resident #1 frequently had pain during the 5 day look back period. The MDS indicated Resident #1's pain did not make it hard for her to sleep at night during the 5 day look back period. The MDS indicated Resident #1's pain did limit her day to day activities during the 5 day look back period. The MDS indicated Resident #1 rated her worst pain at a 5 on the 0-10 pain scale (zero being no pain and ten as the worst pain you can imagine) during the 5 day look back period. The MDS indicated Resident #1 had not received prn pain medication during the 5 day look back period. Record review of the care plan revised on 9/18/23 indicated Resident #1 was to be monitored for pain/ discomfort and was to be administered medications as needed for discomfort and pain. Record review of the physician order dated 8/18/23 indicated Resident #1 was to be administered Hydrocodone -Acetaminophen 7.5mg/325mg 1 tablet every 8 hours as needed for pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676007 If continuation sheet Page 4 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676007 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Rehab & Nursing 1901 Whippoorwill Kilgore, TX 75662 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Record review of the facility-controlled drug record for Resident #1's Hydrocodone -Acetaminophen 7.5mg/325mg dated 8/19/23 to 10/5/23 indicated she had been administered Hydrocodone -Acetaminophen 7.5mg/325mg 1 tablet on the following dates and times; *9/1/2023 at 10:00 a.m.; Residents Affected - Some *9/2/23 at 5:30 a.m.; *9/2/23 at 9:00 p.m.; *9/3/23 at 1:00 p.m.; *9/4/23 at 9:00 a.m.; *9/5/23 at 9:00 a.m.; *9/6/23 at 9:20 a.m.; *9/6/23 at 11:00 p.m.; *9/7/23 at 3:45 p.m.; *9/8/23 at 8:00 a.m.; *9/9/23 at 8:00 a.m.; *9/10/23 at 9:00 a.m.; *9/10/23 at 5:00 p.m.; *9/11/23 at 8:00 a.m.; *9/11/23 at 4:00 p.m.; *9/12/23 at 8:00 a.m.; *9/12/23 at 7:00 p.m.; *9/13/23 at 7:00 a.m.; *9/13/23 at 3:00 p.m.; *9/14/23 at 8:00 a.m.; *9/15/23 at 3:35 p.m.; *9/16/23 at 9:45 a.m.; *9/17/23 at 9:15 a.m.; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676007 If continuation sheet Page 5 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676007 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Rehab & Nursing 1901 Whippoorwill Kilgore, TX 75662 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 *9/18/23 at 8:00 a.m.; Level of Harm - Minimal harm or potential for actual harm *9/18/23 at 6:00 p.m.; *9/19/23 at 2:00 a.m.; Residents Affected - Some *9/19/23 at 9:00 a.m.; *9/20/23 at 9:45 a.m.; *9/21/23 at 12:30 p.m.; *9/21/23 at 9:50 p.m.; *9/22/23 at 8:00 a.m.; *9/22/23 at 3:30 p.m.; *9/23/23 at 8:00 a.m.; *9/24/23 at 8:00 a.m.; *9/24/23 at 3:30 p.m.; *9/24/23 at 8:00 a.m.; *9/25/23 at 8:45 a.m.; *9/25/23 at 8:00 p.m.; *9/26/23 at 8:30 a.m.; *9/26/23 at 4:30 p.m.; *9/27/23 at 8:00 a.m.; *9/27/23 (time not legible); *9/28/23 at 7:00 a.m.; *9/28/23 at 3:00 p.m.; *9/29/23 at 9:30 a.m.; *9/30/23 at 8:00 a.m.; *9/30/23 at 2:00 p.m.; *10/01/23 at 9:15 a.m.; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676007 If continuation sheet Page 6 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676007 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Rehab & Nursing 1901 Whippoorwill Kilgore, TX 75662 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 *10/01/23 at 8:00 p.m.; Level of Harm - Minimal harm or potential for actual harm *10/02/23 at 8:00 a.m.; *10/03/23 at 8:00 a.m.; and Residents Affected - Some *10/05/23 at 10:30 a.m. The facility-controlled drug record did not document Resident #1's pain level with any of the medication administrations. Record review of Resident #1's MAR for September 2023 did not record any administration of Hydrocodone -Acetaminophen 7.5mg/325mg 1 tablet every 8 hours as needed for pain. There were no follow up pain assessments documented on the MAR. Record review of Resident #1's MAR for October 2023 did not record any administration of Hydrocodone -Acetaminophen 7.5mg/325mg 1 tablet every 8 hours as needed for pain. There were no follow up pain assessments documented on the MAR. Record review of the nursing notes from 9/1/23 to 10/5/23 indicated a follow up pain assessment had not been completed after the administration of Resident #1's pain medication (Hydrocodone -Acetaminophen 7.5mg/325mg 1 tablet every 8 hours as needed for pain) on the following dates and times; *9/1/2023 at 10:00 a.m.; *9/2/23 at 5:30 a.m.; *9/2/23 at 9:00 p.m.; *9/3/23 at 1:00 p.m.; *9/4/23 at 9:00 a.m.; *9/5/23 at 9:00 a.m.; *9/6/23 at 9:20 a.m.; *9/6/23 at 11:00 p.m.; *9/7/23 at 3:45 p.m.; *9/8/23 at 8:00 a.m.; *9/9/23 at 8:00 a.m.; *9/10/23 at 9:00 a.m.; *9/10/23 at 5:00 p.m.; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676007 If continuation sheet Page 7 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676007 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Rehab & Nursing 1901 Whippoorwill Kilgore, TX 75662 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 *9/11/23 at 8:00 a.m.; Level of Harm - Minimal harm or potential for actual harm *9/11/23 at 4:00 p.m.; *9/12/23 at 8:00 a.m.; Residents Affected - Some *9/12/23 at 7:00 p.m.; *9/13/23 at 7:00 a.m.; *9/13/23 at 3:00 p.m.; *9/14/23 at 8:00 a.m.; *9/15/23 at 3:35 p.m.; *9/16/23 at 9:45 a.m.; *9/17/23 at 9:15 a.m.; *9/18/23 at 8:00 a.m.; *9/18/23 at 6:00 p.m.; *9/19/23 at 2:00 a.m.; *9/19/23 at 9:00 a.m.; *9/20/23 at 9:45 a.m.; *9/21/23 at 12:30 p.m.; *9/21/23 at 9:50 p.m.; *9/22/23 at 8:00 a.m.; *9/22/23 at 3:30 p.m.; *9/23/23 at 8:00 a.m.; *9/24/23 at 8:00 a.m.; *9/24/23 at 3:30 p.m.; *9/24/23 at 8:00 a.m.; *9/25/23 at 8:45 a.m.; *9/25/23 at 8:00 p.m.; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676007 If continuation sheet Page 8 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676007 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Rehab & Nursing 1901 Whippoorwill Kilgore, TX 75662 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 *9/26/23 at 8:30 a.m.; Level of Harm - Minimal harm or potential for actual harm *9/26/23 at 4:30 p.m.; *9/27/23 at 8:00 a.m.; Residents Affected - Some *9/27/23 (time not legible); *9/28/23 at 7:00 a.m.; *9/28/23 at 3:00 p.m.; *9/29/23 at 9:30 a.m.; *9/30/23 at 8:00 a.m.; *9/30/23 at 2:00 p.m.; *10/01/23 at 9:15 a.m.; *10/01/23 at 8:00 p.m.; *10/02/23 at 8:00 a.m.; *10/03/23 at 8:00 a.m.; and *10/05/23 at 10:30 a.m. During an interview on 10/12/23 at 2:00 p.m., ADON G identified the signatures of LVN E, LVN A, LVN F, and RN I on the facility-controlled drug record for Resident #1's Hydrocodone -Acetaminophen 7.5mg/325mg dated 8/19/23 to 10/5/23. During an interview on 10/12/23 at 3:00 p.m., Resident #1 was laying in her bed. Resident #1 said the facility did give her pain medication. Resident #1 said she usually asked for her pain medication almost daily and sometimes more than once a day. Resident #1 said the pain medication usually helped her pain but there had been sometimes she would ask for the pain medication and the staff would tell her it was not time yet. Resident #1 could not specify any dates when she asked and was told it was not time yet. Resident #1 said she was not hurting at the moment. Record review of the facility-controlled drug record for Resident #1's Hydrocodone -Acetaminophen 7.5mg/325mg dated 8/19/23 to 10/5/23 after ADON G identified signatures revealed: LVN A had signed administration of the Hydrocodone -Acetaminophen 7.5mg/325mg to Resident #1 twenty-two times. LVN F had signed administration of the Hydrocodone -Acetaminophen 7.5mg/325mg to Resident #1 twenty times. RN I had signed administration of the Hydrocodone -Acetaminophen 7.5mg/325mg to Resident #1 six times. LVN E had signed administration of the Hydrocodone -Acetaminophen 7.5mg/325mg to Resident #1 three times. During an interview on 10/16/23 at 11:30 a.m., LVN A identified 22 of the signatures on the facility-controlled drug record for Resident #1's Hydrocodone -Acetaminophen 7.5mg/325mg dated 8/19/23 to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676007 If continuation sheet Page 9 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676007 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Rehab & Nursing 1901 Whippoorwill Kilgore, TX 75662 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 10/5/23 as being her signatures. LVN A said she did administer the medication. When asked why she had not recorded the administrations on the MAR, LVN A said she had came back to the facility a few months ago and the EMR system that was being used was new to her. LVN A said they (the nurses) were just signing in out on the narcotic sheet (facility-controlled drug record) and administering it (the Hydrocodone-Acetaminophen 7.5mg/325mg). LVN A said she should have documented the administrations on the MAR. LVN A said no follow up assessment was completed unless it was in the nursing notes. LVN A said that was another reason she should have documented the administration of pain medication on the MAR because the EMR system would have prompted her to document a follow up pain assessment. LVN A said a follow up pain assessment after the administration of pain medication should be performed and documented for all residents to ensure effectiveness of the medication. LVN A said a pain assessment should have been documented with the administration as well. During an interview on 10/16/23 at 11:49 a.m., LVN E said she knew the Hydrocodone -Acetaminophen 7.5mg/325mg should have been documented on MAR with an assessment of her (Resident #1's) pain at the time of the administration and after the medication had been administered to ensure effectiveness. LVN E said the EMR system will prompt a reassessment when the medication is documented on MAR. When asked why she had not signed the MAR for her administrations of Resident #1's Hydrocodone -Acetaminophen 7.5mg/325mg, she said she thought she had done so. During an interview on 10/16/23 at 12:12 a.m., LVN F said the administration of Resident #1's Hydrocodone -Acetaminophen 7.5mg/325mg was really only being documented in the narcotic book (facility-controlled drug record). LVN F said he knew the Hydrocodone -Acetaminophen 7.5mg/325mg should have been documented on MAR with an assessment of her (Resident #1's) pain at the time of the administration and after the medication had been administered to ensure effectiveness. LVN F said it was just failure on his part to ensure he documented in the MAR. A phone interview with RN I was attempted on 10/16/23 but was not completed. During an interview on 10/16/23 at 3:30 p.m., ADON G said she expected nurses to assess a resident's pain level when administering a prn pain medication and expected them to reassess for effectiveness within an hour. ADON G said it was not acceptable the nurses were not documenting on the MAR and were only signing the narcotic book (facility-controlled drug record). During an interview on 10/16/23 at 3:34 p.m., ADON H currently the facility did not have a DON and the corporate RN was filling in. ADON H said she expected nurses to assess a resident's pain level when administering a prn pain medication and expected them to reassess for effectiveness within an hour. ADON H said it was not acceptable the nurses were not documenting on the MAR and were only signing the narcotic book (facility-controlled drug record). ADON G said had they signed the MAR the would have been prompted to complete assessment at administration of the pain medication and prompted to perform a follow- up pain assessment. ADON G said there had not been any system in place to ensure nurses were documenting prn pain medications on the MAR nor had there been a system in place to ensure pain assessments were being documented with prn pain medication administration/follow-up pain assessments were being completed/documented. ADON H said she began an in-service over these items on 10/12/23 when it was brought to her attention by the surveyor that there was no documentation on Resident #1's MAR for the Hydrocodone -Acetaminophen 7.5mg/325mg signed out of the facility-controlled drug record. During an interview on 10/16/23 at 4:00 p.m., the Administrator said he expected nurses to document pain medication administration and assess the resident to make sure their pain was relieved. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676007 If continuation sheet Page 10 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676007 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Rehab & Nursing 1901 Whippoorwill Kilgore, TX 75662 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the facility policy and procedure titled, Pain Management dated 10/24/2 found the policy and procedure stated, The facility must ensure that pain management is provided to residents who require such services , consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences .Pain Evaluation: the facility will use a pain evaluation tool, which is appropriate for the resident's cognitive status to assist staff in consistent evaluation of a resident's pain .(8) Monitoring , Reevaluation and Care Plan Revision (a) Facility staff will reassess resident's pain management at established intervals for effectiveness . The website https://www.ncbi.nlm.nih.gov/books/NBK2658/ , with the National Library of Medicine accessed on 10/19/23 stated .Improving the Quality of Care Through Pain Assessment and Management . Assessment of pain is a critical step to providing good pain management. In a sample of physicians and nurses, [NAME] and colleagues21 found lack of pain assessment was one of the most problematic barriers to achieving good pain control. The most critical aspect of pain assessment is that it is done on a regular basis (e.g., once a shift, every 2 hours) using a standard format . To meet the patients' needs, pain should be reassessed after each intervention to evaluate the effect and determine whether modification is needed . Documentation of pain assessment and the effect of interventions are essential to allow communication among clinicians about the current status of the patient's pain and responses to the plan of care . American Pain Society Current Guidelines-One of the first quality improvement programs was developed by the American Pain Society .Recognize and treat pain promptly .Reassess and adjust pain management plan as needed .Monitor processes and outcomes of pain management . Assessment of effect should be based upon the onset of action of the drug administered; for example, IV opioids are reassessed in 15-30 minutes, whereas oral opioids and nonopioids are reassessed 45-60 minutes after administration . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676007 If continuation sheet Page 11 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676007 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Rehab & Nursing 1901 Whippoorwill Kilgore, TX 75662 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the medical record of each resident was accurately documented in accordance with accepted professional standards and practices for 1 of 3 residents (Resident #1) reviewed for medical records. The facility failed to ensure the documentation of Resident #1's prn (as needed) pain medication was documented in the MAR. This failure could place residents at risk of delayed pain medication administration, or over medication. Findings included: Record review of the physician order summary report dated 10/5/23 indicated she re-admitted to the facility on [DATE] with diagnoses including history of bladder cancer, breast cancer, high blood pressure, heart failure, presence of vascular implants and grafts, chronic embolism(blockage in an artery, caused by a foreign body, such as a blood clot) and thrombosis (formation of a blood clot (partial or complete blockage) within blood vessels, whether venous or arterial) of deep veins to both lower extremities, history of gastrointestinal hemorrhage, presence of ileostomy (a stoma surgically constructed by bringing the end or loop of small intestine out onto the surface of the skin) morbid (severe) obesity, Stage 2 chronic kidney disease (stages if kidney disorder range from Stage 1 [mild] to Stage 5 [most severe]), history of acute kidney failure, history of acute cystitis(inflammation of the bladder, usually caused by a bladder infection), and neuromuscular dysfunction of the bladder. Record review of the MDS dated [DATE] indicated Resident #1 made herself understood and usually understood others. The MDS indicated she had intact cognition, (BIMS of 13). The MDS indicated she was totally dependent on staff for bed mobility, dressing, personal hygiene, and bathing. The MDS indicated she required extensive assistance with toilet use. The MDS indicated transfers and locomotion in her wheelchair had only occurred once or twice during the 7 day look back period. The MDS indicated Resident #1 frequently had pain during the 5 day look back period. The MDS indicated Resident #1's pain did not make it hard for her to sleep at night during the 5 day look back period. The MDS indicated Resident #1's pain did limit her day to day activities during the 5 day look back period. The MDS indicated Resident #1 rated her worst pain at a 5 on the 0-10 pain scale (zero being no pain and ten as the worst pain you can imagine) during the 5 day look back period. The MDS indicated Resident #1 had not received prn pain medication during the 5 day look back period. Record review of the care plan revised on 9/18/23 indicates Resident #1 was to be monitored for pain/ discomfort and was to be administered medications as needed for discomfort and pain. Record review of the physician order dated 8/18/23 indicated Resident #1 was to be administered Hydrocodone -Acetaminophen 7.5mg/325mg 1 tablet every 8 hours as needed for pain. Record review of the facility-controlled drug record for Resident #1's Hydrocodone -Acetaminophen 7.5mg/325mg dated 8/19/23 to 10/5/23 indicated she had been administered Hydrocodone -Acetaminophen 7.5mg/325mg 1 tablet on the following dates and times; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676007 If continuation sheet Page 12 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676007 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Rehab & Nursing 1901 Whippoorwill Kilgore, TX 75662 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 *9/1/2023 at 10:00 a.m.; Level of Harm - Minimal harm or potential for actual harm *9/2/23 at 5:30 a.m.; *9/2/23 at 9:00 p.m.; Residents Affected - Some *9/3/23 at 1:00 p.m.; *9/4/23 at 9:00 a.m.; *9/5/23 at 9:00 a.m.; *9/6/23 at 9:20 a.m.; *9/6/23 at 11:00 p.m.; *9/7/23 at 3:45 p.m.; *9/8/23 at 8:00 a.m.; *9/9/23 at 8:00 a.m.; *9/10/23 at 9:00 a.m.; *9/10/23 at 5:00 p.m.; *9/11/23 at 8:00 a.m.; *9/11/23 at 4:00 p.m.; *9/12/23 at 8:00 a.m.; *9/12/23 at 7:00 p.m.; *9/13/23 at 7:00 a.m.; *9/13/23 at 3:00 p.m.; *9/14/23 at 8:00 a.m.; *9/15/23 at 3:35 p.m.; *9/16/23 at 9:45 a.m.; *9/17/23 at 9:15 a.m.; *9/18/23 at 8:00 a.m.; *9/18/23 at 6:00 p.m.; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676007 If continuation sheet Page 13 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676007 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Rehab & Nursing 1901 Whippoorwill Kilgore, TX 75662 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 *9/19/23 at 2:00 a.m.; Level of Harm - Minimal harm or potential for actual harm *9/19/23 at 9:00 a.m.; *9/20/23 at 9:45 a.m.; Residents Affected - Some *9/21/23 at 12:30 p.m.; *9/21/23 at 9:50 p.m.; *9/22/23 at 8:00 a.m.; *9/22/23 at 3:30 p.m.; *9/23/23 at 8:00 a.m.; *9/24/23 at 8:00 a.m.; *9/24/23 at 3:30 p.m.; *9/24/23 at 8:00 a.m.; *9/25/23 at 8:45 a.m.; *9/25/23 at 8:00 p.m.; *9/26/23 at 8:30 a.m.; *9/26/23 at 4:30 p.m.; *9/27/23 at 8:00 a.m.; *9/27/23 (time not legible); *9/28/23 at 7:00 a.m.; *9/28/23 at 3:00 p.m.; *9/29/23 at 9:30 a.m.; *9/30/23 at 8:00 a.m.; *9/30/23 at 2:00 p.m.; *10/01/23 at 9:15 a.m.; *10/01/23 at 8:00 p.m.; *10/02/23 at 8:00 a.m.; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676007 If continuation sheet Page 14 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676007 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Rehab & Nursing 1901 Whippoorwill Kilgore, TX 75662 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 *10/03/23 at 8:00 a.m.; and Level of Harm - Minimal harm or potential for actual harm *10/05/23 at 10:30 a.m. Residents Affected - Some Record review of Resident #1's MAR for September 2023 did not record any administration of Hydrocodone -Acetaminophen 7.5mg/325mg 1 tablet every 8 hours as needed for pain. Record review of Resident #1's MAR for October 2023 did not record any administration of Hydrocodone -Acetaminophen 7.5mg/325mg 1 tablet every 8 hours as needed for pain. There were no follow up pain assessments documented on the MAR. During and interview on 10/12/23 at 2:00 p.m., ADON G identified the signatures of LVN E, LVN A, LVN F, and RN I on the facility-controlled drug record for Resident #1's Hydrocodone -Acetaminophen 7.5mg/325mg dated 8/19/23 to 10/5/23. During an interview on 10/12/23 at 3:00 p.m., Resident #1 was laying in her bed. Resident #1 said the facility did give her pain medication. Resident #1 said she usually asked for her pain medication almost daily and sometimes more than once a day. Resident #1 said the pain medication usually helped her pain but there had been sometimes she would ask for the pain medication and the staff would tell her it was not time yet. Resident #1 could not specify any dates when she asked and was told it was not time yet. Resident #1 said she was not hurting at the moment. Record review of the facility-controlled drug record for Resident #1's Hydrocodone -Acetaminophen 7.5mg/325mg dated 8/19/23 to 10/5/23 after ADON G identified signatures revealed: LVN A had signed administration of the Hydrocodone -Acetaminophen 7.5mg/325mg to Resident #1 twenty-two times. LVN F had signed administration of the Hydrocodone -Acetaminophen 7.5mg/325mg to Resident #1 twenty times. RN I had signed administration of the Hydrocodone -Acetaminophen 7.5mg/325mg to Resident #1 six times. LVN E had signed administration of the Hydrocodone -Acetaminophen 7.5mg/325mg to Resident #1 three times. During an interview on 10/16/23 at 11:30 a.m., LVN A identified 22 of the signatures on the facility-controlled drug record for Resident #1's Hydrocodone -Acetaminophen 7.5mg/325mg dated 8/19/23 to 10/5/23 as being her signatures. LVN A said she did administer the medication. When asked why she had not recorded the administrations on the MAR, LVN A said she came back to the facility a few months ago and the EMR system that was being used was new to her. LVN A said we (the nurses) were just signing in out on the sheet and administering it (the Hydrocodone -Acetaminophen 7.5mg/325mg). LVN A said she had been shown how to document in the MAR when she came back to the facility a few months ago and LVN A said she had been shown how to document in the MAR and should have documented the administrations on the MAR . During an interview on 10/16/23 at 11:49 a.m., LVN E said she knew the Hydrocodone -Acetaminophen 7.5mg/325mg should have been documented on MAR and thought she had done so. During an interview on 10/16/23 at 12:12 a.m., LVN F said the administration of Resident #1's Hydrocodone -Acetaminophen 7.5mg/325mg was really only being documented in the narcotic book (facility-controlled drug record). LVN F said he knew the Hydrocodone -Acetaminophen 7.5mg/325mg should have been documented on MAR. During an interview on 10/16/23 at 3:34 p.m., ADON H currently the facility did not have a DON and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676007 If continuation sheet Page 15 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676007 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Rehab & Nursing 1901 Whippoorwill Kilgore, TX 75662 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the corporate RN was filling in. ADON H said it was not acceptable the nurses were not documenting on the MAR and were only signing the narcotic book (facility-controlled drug record). ADON G said the signing out of the drug by the nurse in the narcotic book indicates time and date the medication was pulled and the count (the amount of remaining) of the narcotic. ADON G said it was not intended to be the administration record. ADON G said had they signed the MAR they would have been prompted to complete assessment at administration of the pain medication and prompted to perform a follow- up pain assessment. ADON G said there had not been any system in place to ensure nurses were documenting prn pain medications on the MAR nor had there been a system in place to ensure pain assessments were being documented with prn pain medication administration/follow-up pain assessments were being completed/documented. ADON H said she began an in-service over these items on 10/12/23 when it was brought to her attention by the surveyor that there was no documentation on Resident #1's MAR for the Hydrocodone -Acetaminophen 7.5mg/325mg signed out of the facility-controlled drug record. During an interview on 10/16/23 at 4:00 p.m., the Administrator said he expected nurses to document pain medication administration on the MAR and ensure completeness and accuracy of the medical record. Record review of the facility policy and procedure titled Documentation Guideline, revised on 3/25/14 found the policy and procedure stated, The patient's clinical record provides a record of health status .and serves as the primary document describing the healthcare services provided to the patient . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676007 If continuation sheet Page 16 of 16