Health inspection·June 13, 2025

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who needs respiratory care, is provided such care consistent with professional standards of practice for 1 of 2 residents (Resident #1) reviewed for respiratory care. Residents Affected - Few The facility failed to ensure that CNA B effectively communicated to RN A that Resident #1 requested a nurse. The facility failed to ensure that CNA B recognized a change of condition in Resident #1 that needed to be emergently communicated to RN A. The facility failed to ensure CNA C reported Resident #1's change of condition to RN A. These failures resulted in Resident #1 presenting with signs and symptoms of acute respiratory distress, a medical emergency and delayed her transfer of care to the acute care facility on 5/18/25 where she was diagnosed with acute hypercapnic respiratory failure ( a serious medical condition where the lungs cannot adequately remove carbon dioxide (CO2) from the blood, leading to a buildup of CO2 and a dangerously low blood pH) An Immediate Jeopardy (IJ) was identified on 6/5/25. The IJ template was provided to the facility on 6/5/25 at 5:30 pm. While the IJ was removed on 6/6/25 at 2:37 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to monitor and evaluate the effectiveness of their corrective systems. This failure could place residents requiring respiratory care at risk for exacerbation of condition, as well as placing any residents needing emergency attention at risk for deterioration, irreversible health complications and death. The findings included: Record review of the face sheet dated 6/5/25 for Resident #1 indicated she was re-admitted to the facility on [DATE] with diagnoses including, acute on chronic respiratory failure with hypoxia (occurs when a person with a pre-existing chronic lung condition experiences a sudden worsening of their respiratory status, leading to dangerously low oxygen levels in the blood [hypoxia]), acute on chronic respiratory failure with hypercapnia (sudden worsening of a patient's breathing, where their lungs can't adequately remove carbon dioxide [hypercapnia] and this occurs on top of an existing, long-term respiratory condition), pneumonia, atrial fibrillation (an irregular heart beat that causes the Page 1 of 8 676007 676007 06/13/2025 Willow Rehab & Nursing 1901 Whippoorwill Kilgore, TX 75662

F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few heat to beat rapidly and irregularly, causing the heart to not pump blood efficiently, symptoms can include palpitations, shortness of breath, dizziness if left untreated this heart rhythm can lead to blood clots, stroke and heart failure), acute pulmonary edema (sudden and severe condition where fluid accumulates in the lungs, making it difficult to breathe. It's a medical emergency requiring immediate treatment). Record review of the MDS dated [DATE] indicated Resident #1 made herself understood and understood others. The MDS indicated Resident #1 was unable to complete the interview for BIMS. The sections of the MDS inquiring of short-term memory; Long-term memory; memory /recall ability; and cognitive skills for decision making were not answered. The MDS indicated there was no evidence of acute change in metal status from the resident's baseline. The MDS indicated Resident #1 no behaviors of inattention, disorganized thinking, or altered level of consciousness. The MDS indicated Resident #1 had no behavior of rejecting care. The MDS indicated Resident #1 was dependent on staff for toileting, showers/baths, lower body dressing, putting on/taking off of footwear. The MDS indicated Resident #1 required substantial/ maximal assistance with upper body dressing and personal hygiene. The MDS indicated Resident #1 required supervision, or touching assistance with oral hygiene and required only setup or clean -up assistance with eating. The MDS indicated Resident #1 required substantial maximal assistance with the following position changes; sit to lying (The ability to move from sitting on side of bed to lying flat on bed); lying to sitting on the side of bed (the ability to move from lying on back to sitting on the side of the bed with no back support); sit to stand (the ability to come to a standing position from sitting in a chair , wheelchair or on the side of the bed). The MDS indicated Resident #1 required partial/moderate assistance with roll left to right (the ability to roll from lying on back to the left and right side and return to lying on back on the bed). The MDS indicated toilet transfers, tub/shower transfers, car transfers and walking 10 feet were not attempted due to medical condition or safety concerns. The MDS indicated Resident #1 was frequently incontinent of bowel and bladder. The MDS indicated Resident #1's primary medical condition was debility, cardiorespiratory conditions. The MDS indicated active diagnoses included Atrial Fibrillation or other dysrhythmias, heart failure, pneumonia, seizure disorder, and respiratory failure. Record review of the discharge MDS dated [DATE] indicated Resident #1 had no cognitive impairment (BIMS of 15). Record review of the care plan revised on 3/24/25 indicated Resident #1 had a diagnosis of altered cardiovascular status due to arrythmia, CHF (congestive heart failure). The care plan interventions included, monitor resident for shortness of breath and cyanosis ( a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood). The care plan indicated Resident #1 had impaired respiratory status and was at risk for shortness of breath, respiratory distress, increased anxiety and hypoxia. The care plan interventions included monitor for shortness of breath, respiratory distress and provide oxygen as ordered. Record review of Resident #1's order summary report as of 5/18/2025, detailed and active order to change o2 tubing and humidifier bottle every night shift every Sunday. As well as an active order to administer oxygen via nasal cannula to maintain SP02 >92 %every shift related to acute and chronic respiratory failure. Record review of the nursing note for Resident #1 dated 5/18/25 at 10 40 p.m., stated RN to room to change o2 (oxygen) tubing and humidifier bottle as order(ed). Roommate states she had been trying 676007 Page 2 of 8 676007 06/13/2025 Willow Rehab & Nursing 1901 Whippoorwill Kilgore, TX 75662

F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few to get the nurse for a while and reports she hit the call light and told the CNA that came into the room that (Resident #1) needed the nurse. The nurse was not informed of the resident's request for a nurse. Visual assessment showed the resident to be lying on her left side and she had inadvertently disconnected herself from the oxygen concentrator. The resident was noted to have dusky color, blue fingertips, and shallow respiration. The resident (Resident #1) was immediately placed back on the oxygen concentrator and pulse oximeter reading of 50% oxygen increased to 5 LPM with continuous SP02 monitoring. SpO2 only rose to 70%. 911 was called for emergent transport and immediately placed on non-rebreather at 15 LPM bringing Sp02 up to 94%. This note was written by RN A. Record review of the hospital Discharge summary dated [DATE] indicated Resident #1 was admitted to the hospital on [DATE] with diagnosis of acute hypercapnic respiratory failure. The discharge summary detailed Resident #1 developed severe hypoxia ( critical state where the body's tissues and organs are deprived of adequate oxygen) and hypercapnia ( condition where there is an excessive buildup of carbon dioxide (CO2) in the bloodstream) with lab work and chest x-ray indicating concurrent heart failure exacerbation (sudden worsening of heart failure symptoms, where the heart can no longer effectively pump enough blood to meet the body's needs) and was in chronic atrial fibrillation (also known as long-standing persistent atrial fibrillation, is a heart condition where the upper chambers of the heart [atria] beat irregularly and rapidly for extended periods) on admission . She was treated and discharged back to the nursing facility on 5/20/25. During an interview on 6/4/25 at 12:00 p.m., RN A said CNA B never told her that Resident #1 needed a nurse. RN A said she just happened to go into Resident #1's room when she did because she was changing the oxygen tubing and humidifier as it was ordered to be done on her shift. RN A said when she went into the room it was obvious Resident #1 was respiratory distress. RN A said Resident #1 fingers were blue she was breathing rapid shallow breaths. RN A said her oxygen tubing was disconnected from concentrator, although the nasal cannula remained in her nose. RN A said she put a pulse on oximeter on Resident #1 and Sp02 reading was in the 50's. RN A said she retrieved a mask and turned Resident #1's oxygen up to 5 liters per minute and Sp02 reading came up to the 70's. RN A said she called 911. RN A said when EMS arrived , they had gotten her Spo2 up to 94% on 15 liters per minute before she was transferred to the hospital. RN A said she was very upset that CNA B had not notified her that Resident #1 had requested a nurse. RN A said she would have went to the room right away had she known Resident #1 needed the nurse. RN A said she notified the DON that night of the situation and that CNA B had not notified her (RN A) Resident #1 needed her. During an interview and observation on 6/5/25 at 12:20 p.m., Resident #1 sat in her wheelchair in her room. Resident #1 said she had been to the hospital recently. Resident #1 said she could not recall the exact date and stated she thought it had been a few weeks ago. Resident #1 said the day she went to the hospital she was very light headed and felt the room was spinning. Resident #1 said she had COPD (chronic obstructive pulmonary disease is a progressive lung disease that causes airflow obstruction and breathing difficulties), Afib (atrial fibrillation) and seizure disorder. Resident #1 said she felt like something was wrong and could not catch her breath. Resident #1 said her memory of the event was a little fuzzy and stated her roommate (Resident #2) was in the room with her. Resident #1 said she called for help and CNA B came to the room and helped her set the bed up. Resident #1 said she was feeling really dizzy and short of breath when her roommate had called to get her a nurse. Resident #1 said it seemed like maybe 30 minutes before the nurse came but she really was not sure exactly how long it was before the nurse came in the room. Record review of the face sheet for Resident #2, dated 6/5/25 indicated she was readmitted to the facility on [DATE] with diagnoses including, spinal stenosis, PVD (peripheral vascular disease), 676007 Page 3 of 8 676007 06/13/2025 Willow Rehab & Nursing 1901 Whippoorwill Kilgore, TX 75662

F 0695 morbid obesity and muscle weakness. Level of Harm - Immediate jeopardy to resident health or safety Record review of the MDS dated [DATE] for Resident #2 indicated she understood others and made herself understood. The MDS indicated Resident #2 had no cognitive impairment (BIMS of 15). The MDS indicated Resident #2 had limited range of motion to both lower extremities and to one upper extremity. The MDS indicated Resident #2 used a wheelchair for mobility. The MDS indicated Resident #2 required substantial/ maximal assistance with sit to lying position changes (the ability to move from sitting on side of bed to lying flat on bed) and required partial/moderate assistance with lying to sitting on the side of the bed (the ability to move from lying on back to sitting on the side of the bed with no back support). The MDS indicated Resident #2 was always incontinent of bladder and frequently incontinent of bowel. Residents Affected - Few During an interview on 6/5/25 at 12:28 p.m., Resident #2 said she couldn't recall the exact date of the event but stated it was approximately a few weeks ago. Resident #2 said she noticed her roommate (Resident #1) struggling with her bed remote. Resident #2 said Resident #1 was trying to raise her bed up. Resident #2 said Resident #1 had pushed her call light for help but said she went ahead and put her call light on also to try and get help for roommate. Resident #2 said she couldn't say exactly how long it was before CNA B came to the room but guessed it was about 15 minutes. Resident #2 said CNA B came into the room and she (Resident #2) told her (CNA B) that Resident #1 needed help with her bed remote. Resident #2 said CNA B helped Resident #1 to raise up the head of the bed and left the room. Resident #2 said a few minutes later her roommate (Resident #1) was having trouble talking to her and she (Resident #2) asked her if she needed the nurse. Resident #2 said she could not remember if she said yes or nodded yes but again put on her call light to get her roommate help. Resident #2 said she just knew Resident #1 needed the nurse. Resident #2 said CNA B answered the call light and came to the door. Resident #2 said she told CNA B Resident #1 needed the nurse. Resident #2 said CNA B said she would let the nurse now and left the room. Resident #2 said it was a really long time, she guessed approximately 45 minutes before the nurse came into the room. Record review of the associate disciplinary memorandum for CNA B i ndicated she was suspended on 5/19/25 pending investigation. The description of violation was Employee failed to notify charge nurse on resident change of condition. Employee failed to follow the company's code of conduct, policies and procedures. The memorandum detailed CNA B's comments were taken via phone and stated .She (CNA B) answered resident (Resident #1's) call light and she (Resident #1) needed help with her bed remote. She (CNA B) assisted her, resident (Resident #1) was not in distress. She (CNA B) stated she answered it the second time and the resident (Resident #1) stated she wanted the nurse. (Resident #1) did not appear to be in any distress. She (CNA B) stated the nurse was at the end of another hall. She (CNA B) told her (RN A) down the hall that (room number) wished to speak with her. She (CNA B) said she assumed the nurse went down there. The memorandum detailed Employee has been educated on notifying charge nurse on change of condition. Continued behavior will result in further disciplinary action up to and including termination .(and) Employee should report changes of condition promptly to charge nurse. The disciplinary memorandum was signed by the DON, ADON D, and human resources personnel E. During an interview on 6/5/25 at 2:00 p.m., the DON said RN A had notified her of the incident. The DON said RN A insisted she had not been notified of Resident #1's request for a nurse and CNA B insisted she had notified RN A. The DON said she herself did not take CNA B's statement because she was out of the facility the following day (5/19/25) but stated ADON B and human resources personnel E took her (CNA B's) statement over the phone. The DON said CNA B was in-serviced over notification of 676007 Page 4 of 8 676007 06/13/2025 Willow Rehab & Nursing 1901 Whippoorwill Kilgore, TX 75662

F 0695 Level of Harm - Immediate jeopardy to resident health or safety change of condition. The DON said that in-service (notification of change of condition) was started on 5/19/25 for all clinical staff and was ongoing. During an interview on 6/5/25 at 2:20 p.m., ADON B said she called CNA B to ask her about RN A's allegation of not being notified. ADON B said the statement was as documented on the associate disciplinary memorandum dated 5/19/25 for CNA B. Residents Affected - Few During an interview on 6/5/25 at 2:22 p.m., human resources personnel E said she was also on the call made to CNA B to record her statement. Human resources personnel E said the statement was as documented on the associate disciplinary memorandum dated 5/19/25 for CNA B. During an interview on 6/5/25 at 2:37 p.m., CNA B said, on 5/18/25 she responded to Resident #1's call light. CNA B said when she went into the room she asked Resident #1 what she needed and she indicated she needed help with her bed. CNA B said she assisted Resident #1 with raising the head of her bed up and left the room. CNA B said Resident #1 did not appear to be in any distress and made no further requests at that time. CNA B then said later (she could not quantify time between the first and second call light response) she saw the call light was on again for Resident #1 and responded. CNA B said Resident #2 said Resident #1 needed the nurse. CNA B said do you need the nurse and Resident #1 replied that she did need the nurse. CNA B said Resident #1 was fine and did not appear to be in any distress. CNA B said she left the room and RN A was at the end of another hall and yelled to her that Resident #1 needed her. CNA B said the call light for Resident #1 was on again and at this time she retrieved CNA C to assist her as she anticipated she may need assistance as Resident #1 was a large lady. CNA B said CNA C went into the room with her and they provided peri care for Resident #1. CNA B said Resident #1 was fine and was in no distress when herself and CNA C were in the room. CNA B then said she had told RN A multiple times Resident #1 needed her. CNA B said Resident #1's call light came on again. CNA B said from the time herself and CNA C provided peri-care to the call light coming on again was approximately 30 minutes. CNA B said herself and CNA C walked down to the room and saw RN A squatting down at the bedside. CNA B said every time she was in the room Resident #1 was not in distress and her oxygen was on and connected to the concentrator. During an interview on 6/5/25 at 3:00 p.m., CNA C said when she went to help CNA B with Resident #1 on 5/18/25 she (Resident #1) looked like she was going through something. CNA C said Resident #1 wouldn't open her eyes was breathing hard and kinda shallow. CNA C said they provided peri-care and they continued to ask her (Resident #1) questions but she (Resident #1)would not alk to them. CNA C said Resident #1 did have her oxygen tubing in her nose. CNA C said Resident #2 said Resident #1 needed the nurse. CNA C said she looked at CNA B as they were leaving the room and CNA B said to her, she had already notified the nurse. CNA C said she did not go to RN A herself because CNA B told her (CNA C) she had already notified the nurse. CNA C said the call light came on again and she walked with CNA B down to the room. CNA C said RN A was at the bedside and asked the them (CNA B and CNA C) why the oxygen tubing was disconnected from the concentrator and how long had Resident #1 had trouble breathing. Record review of the facility policy and procedure titled Notification of Changes, dated 7/13/25 stated Policy: To provide guidance on when to communicate acute changes in status to MD, MP and/responsible party. The facility will immediately inform the resident; consult with the resident's physician; and if known notify the resident's legal representative or appropriate family member of the following: .(2) An emergency response situation that require EMS involvement. (3) A significant change in the physical, mental or psychosocial status of the resident . 676007 Page 5 of 8 676007 06/13/2025 Willow Rehab & Nursing 1901 Whippoorwill Kilgore, TX 75662

F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The Administrator was notified on 6/5/25 at 5:25 p.m. at that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided with the Immediate Jeopardy template via email on 6/5/25 at 5:30 p.m. The Plan of Removal was accepted on 6/6/25 at 12:40 p.m.,05/15/25 and detailed the following: .Resident #1 was sent to the ER for evaluation and treatment on 05/18/2025. Resident #1 returned to the facility on 5/20/25; head to toe physical assessment was completed by floor nurse upon return to the facility and documented. The resident was assessed by the Director of Nursing, and she was not in distress and at normal baseline. The Administrator/Director of Nursing reported this allegation of respiratory care failure to the facility Identification of Residents Affected or Likely to be Affected: Director of Nursing/ or Designee conducted assessments for the 13 residents currently on oxygen therapy or with PRN orders, with no negative findings or changes noted. (Completion Date: 06/05/2025) Actions to Prevent Occurrence/Recurrence: 06/06/2025) On 6/5/25 @ 6:30pm the Director of Nursing, Assistant Director of Nursing, Designee in-serviced direct care staff to include CNAs on recognizing notification of change, effective communication and stop and watch. If a resident presents with a change in condition, the nurse will be notified immediately by each CNA verbally and will describe what change they see with the resident. The CNAs will document on the stop and watch tool simultaneously to communicate the change with the nurse and both CNA and nurse will sign the form. This will be completed by 6/6/25 @ 12pm. Any new staff or staff not present will be in-serviced prior to their next shift. On 6/5/25 @ 6:30pm the Director of Nursing, Assistant Director of Nursing, Designee in-serviced direct care staff to include CNAs on job duties and effective communication which includes updating charge nurses throughout shift of patient status or change of condition immediately by using the stop and watch tool. This will be completed by 6/6/25 @ 12pm. Any new staff or staff not present will be in-serviced prior to their shift. On 6/5/25 @ 6:30pm the Director of Nursing, Assistant Director of Nursing, Designee in-serviced floor nurses on the immediate need of nursing assessment when a change of condition is indicated or notified by CNA. This will be completed by 6/6/25 @ 12pm. Any new staff or staff not present will be in-serviced prior to their shift. How the corrective action(s) will be monitored to ensure the practice will not recur: The Administrator, Director of Nursing, Assistant Director of Nursing or designee, will review 676007 Page 6 of 8 676007 06/13/2025 Willow Rehab & Nursing 1901 Whippoorwill Kilgore, TX 75662

F 0695 Level of Harm - Immediate jeopardy to resident health or safety 24-hour report during clinical meeting during morning stand-up daily for any respiratory changes of condition to verify understanding of current policy for recognizing changes of condition, notification, and assessment of residents. Re-education will be provided at the time, if needed. Summary of investigations and incidence of re-education, if required, will be discussed with the facility QAPI committee, and plan may be revised as needed. Residents Affected - Few This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met. An off-cycle Ad Hoc QAPI meeting was held by the Administrator/ or designee on 06/05/2025 at approximately 6:30 pm via phone conversation with Medical Director to discuss the IJ on respiratory services. We discussed the facility's follow-up plan to sustain compliance. On 6/6/25 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During an interview on 6/6/25 at 12:50 p.m., the DON said the facility had 13 residents who had orders for Oxygen, (either continuous or as needed). The DON said all these Residents were assessed on 06/05/25 and there were no concerns with their Oxygen level. The DON said nursing staff including CNAs, Med Aides and Nurses were in-serviced on recognizing change In condition of a resident. The DON said CNAs cannot assess a resident but can report if they see a resident not being normal. The DON said they (CNAs) were to report the change in condition immediately to the charge nurse. The DON said when a change in condition is identified the staff (CNA) and the nurse will document the reported Change on the Stop and Watch paper form. The DON said and both the staff (CNA) and the nurse must sign. The DON said there had not been a change in condition reported since the training. The DON said staff work 12 hours shift from 6AM to 6PM and 6PM to 6AM. The DON said all nursing staff have received the training and any nursing staff not on the schedule, will be trained by the DON, ADON, or designee prior to starting their shift. The DON said most likely the training of new staff or staff who had not yet been on the schedule will be conducted by the DON or ADON B, but it could be another nurse who had already been trained. The DON said the 24-hour Report will be reviewed during morning meeting and any respiratory changes in condition will be reviewed to verify that new procedure was followed and Stop and Watch form was completed and signed as required. The DON said any new concerns with training or the Stop and watch procedure will be reviewed by the QAPI committee any concerns with re-education will be addressed immediately. The DON said an AD Hoc QAPI meeting was conducted with the Medical Director on 06/05/25 to address any issues that were mentioned in the IJ template. The DON provided copies of current employees and completion of training. No issues were identified. The DON provided a list of the 13 residents with oxygen orders. The surveyor reviewed and no concerns were identified. Of these 13 residents the surveyor interviewed Resident #3, #4, #5, #6, and #7 and found no concerns. During interviews on 6/6/25 from 1:00 p.m., to 2:30 p.m., Nurses and Nurse Aides that represent the 6:00 a.m.- 6:00 p.m. and 6:00 p.m. to 6:00 a.m. shifts (LVN F, LVN G, LVN H, LVN I, CNA J, CNA K, CNA L, CNA M, CNA N, CNA O and MA P) as well as confirmed they had received training on reporting 676007 Page 7 of 8 676007 06/13/2025 Willow Rehab & Nursing 1901 Whippoorwill Kilgore, TX 75662

F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few change in Condition and documenting on the Stop and Watch form. They said any time there was a change in Condition, the nurse was to respond immediately to assess the resident. CNAs will document the date and time when the change was reported to the nurse, and which nurse the change was reported. All staff were able to describe the procedure on reporting change in condition and Stop and Watch form. On 6/6/25 at 2:37 p.m., the Administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. 676007 Page 8 of 8