Health inspection·March 24, 2023

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 3 residents (Resident #22) reviewed for beneficiary notices. Residents Affected - Few The facility failed to give Resident #22 a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when she was discharged from skilled services at the facility before her covered days were exhausted. This failure could place residents at risk of not being fully informed about services covered by Medicare. Findings included: Record review of Resident #22's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included Alzheimer's disease with late onset, heart disease, chronic kidney disease, and anxiety. Record review of Resident #22's quarterly MDS assessment dated [DATE] revealed she started occupational therapy on 11/22/22 and ended it on 12/21/22. Record review of Resident #22's Order Summary Report for March 2023 revealed an order to discontinue skilled OT on 12/21/22, order date 12/22/22. Record review of Resident #22's SNF Beneficiary Protection Notification completed by the facility revealed she started Medicare Part A skilled services on 12/1/22 and the last covered day of part A service was on 12/21/22. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted and noted that a SNF ABN, Form CMS-10055 was not issued to the resident when it should have been. In an interview on 3/23/23 at 4:04 p.m. the Business Office Manager said she was new to the facility and was not aware that issuing ABNs was her responsibility unit 1/11/23. She said the purpose of the ABN was to notify the residents of charges they could be responsible for once they went past their Medicare stay. She said the ABN provided the resident with estimated cost of services after the last covered day. She said Resident #22 was supposed to receive an ABN because she remained in the facility for long term care. Page 1 of 14 676244 676244 03/24/2023 Willow Creek Lodge 11830 Northpointe Boulevard Tomball, TX 77377

F 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 3/24/23 at 2:14 p.m. the Administrator said the Business Office Manager became responsible for issuing the ABNs around November or December of 2022. She said she expected the BOM to issue the ABN to the resident. Record review of the facility's Medicare Advance Beneficiary and Medicare Non-Coverage Notices dated September 2022 read in part, .Residents are informed in advance when changes will occur to their bills . Skilled Nursing Facility Advance Beneficiary Notice (CMSS form 10055) 1. If the director of admissions or benefits coordinator believes (upon admission or during the resident's stay) that Medicare (Part A of the Fee for Service Medicare Program) will not pay for an otherwise covered skilled service, the resident (or representative) is notified in writing why the service may not be covered and of the resident's potential liability for payment of the non-covered service. 2. The facility issues the Skilled Nursing Facility Advance Beneficiary Notice for the following triggering events: .b. Reduction . C. Termination . 4. The resident (or representative) is informed that they may choose to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility . 676244 Page 2 of 14 676244 03/24/2023 Willow Creek Lodge 11830 Northpointe Boulevard Tomball, TX 77377

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interviews and records reviewed, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 4 (Director of Food Services Manager, Housekeeping Manager, Certified Nurse Assistant M (CNA M), and Certified Nurse Assistant O (CNA O)) of 17 employees reviewed for employee misconduct registry (EMR)/nurse aide registry (NAR). Residents Affected - Some -The facility failed to check the EMR/NAR annually for 4 of 17 employees. This failure could place residents at an increased risk of abuse, neglect, exploitation, and/or misappropriation of property. The findings included: Record review of facility's undated Employee Chart Check revealed a hire date of 01/18/2021 and an EMR/NAR check date of 01/08/2021 for the Director of Food Services Manager. Further record review of staff's personnel file revealed an EMR/NAR printout with a run date of 01/08/2021. Record review of facility's undated Employee Chart Check revealed a hire date of 10/01/2020 and an EMR/NAR check date of 04/15/2020 for the Housekeeping Director. Further record review of staff's personnel file revealed an EMR/NAR printout with a run date of 04/15/2020. Record review of facility's undated Employee Chart Check revealed a hire date of 10/01/2020 and an EMR/NAR check date of 02/27/2020 for CNA M. Further record review of staff's personnel file revealed an EMR/NAR printout with a run date of 02/27/2020. Record review of facility's undated Employee Chart Check revealed a hire date of 12/24/2021 and an EMR/NAR check date of 12/23/2021 for CNA O. Further record review of staff's personnel file revealed an EMR/NAR printout with a run date of 12/23/2021. During an interview on 03/24/2023 at 2:25 p.m., the Human Resources Manager (HRM) said she had been working at the facility since June 2013. She said she was responsible for running the EMR/NAR checks. She said per Federal and state regulations they were only required to be checked before hire. She said she did not run them at any other time. She said she received regulation training on when to run EMR/NAR checks from her corporate human resources office. She said she was instructed by the facility to run them annually. During an interview on 03/24/2023 at 3:40 p.m., the Administrator said the HRM was responsible for running the EMR/NAR checks. She said per regulations, the checks should be run before hire and upon the employee's anniversary date. She said the facility has an audit tool they utilize to ensure the EMR/NAR are being checked annually. She said she was not aware that all employees' checks had not been run annually. She said the facility's corporate human resources director sent out a memo, around November or December 2022, informing the facility that it was time to run annual background checks. She said not running the EMR/NAR checks annually could place residents at risk for abuse, neglect, and/or misappropriation of property. Record review of Annual Background Checks memo dated 11/28/2022 from the facility's corporate human resources director, read in part: 676244 Page 3 of 14 676244 03/24/2023 Willow Creek Lodge 11830 Northpointe Boulevard Tomball, TX 77377

F 0607 It's that time of the year where we need to run our annual background checks for staff to stay in compliance. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's Abuse Policy dated 10/01/202, read in part: Residents Affected - Some Policy It is the policy of [facility name] to prohibit resident or patient abuse or neglect in any form . The Executive Director is designated the Abuse Coordinator for [facility name]. Procedure 1. Screening: a. Pre-employment screening will be completed on all employees, to include: Professional licensure, certification, or registry check as applicable (pre-hire and annually) Employee Misconduct Registry (EMR)- pre-hire and annually. 676244 Page 4 of 14 676244 03/24/2023 Willow Creek Lodge 11830 Northpointe Boulevard Tomball, TX 77377

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents for one (Resident #37) of eight residents reviewed for falls. The facility failed to prevent Resident #37's avoidable accident when the anti-tippers (bars that prevent the wheelchair from falling over) were positioned incorrectly on his wheelchair. Resident #37 was transferred from his bed to his wheelchair and fell backwards, hitting his head and sustaining pain to the left knee. The facility failed to ensure Resident #37 was assessed for injuries by a nurse prior to being picked up from the floor. This failure could place residents at risk for injury, hospitalization, and death. Findings included: Record review of Resident #37's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included spondylosis (age-related wear and tear affecting the spinal disks), hemiplegia affecting left nondominant side (paralysis of one side of the body), chronic pain syndrome, unspecified lack of coordination, and need for assistance with personal care. Record review of Resident #37's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 which indicated intact cognition. He required extensive assistance of one staff for transfers. Record review of Resident #37's Incident Report dated 3/20/23 written by the DON read in part, .Nursing Description: CNA assisted resident with transfer from bed to wheelchair. CNA made sure that wheelchairs were locked before transfer . Upon sitting on the wheelchair, resident wheelchair fell backwards. PT and OT came and assisted CNA to get resident and wheelchair back up. Writer came, according to resident he hit his head . Immediate Action Taken: Upon writer's assessment, wheelchair brakes in good working condition, but anti tippers noted to be facing upward, instead of downward for safety. It prevents wheelchairs going over backwards. Correctly position anti tippers immediately by writer and social at this time . Injuries Report Post Incident: No injuries observed post incident . Record review of Resident #37's Progress Note dated 3/20/23 written by LVN R read in part, .x ray to the left knee for the diagnosis of pain . Record review of Resident #37's Progress Note dated 3/20/23 written by LVN R read in part, .left knee xray results in, called to notify MD but was unable to reach him, then left a message and a call back number . Record review of Resident #37's Progress Note dated 3/21/23 written by LVN V read in part, .acetaminophen 500 mg give 1 tablet . as needed for pain . 676244 Page 5 of 14 676244 03/24/2023 Willow Creek Lodge 11830 Northpointe Boulevard Tomball, TX 77377

F 0689 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #37's Incident Note dated 3/21/23 at 9:34 a.m. written by LVN V read in part, .s/p fall 1/3, c/o pain early this shift, medicated with prn with good result neuro in progress . Record review of Resident #37's Incident Note dated 3/22/23 written by LVN V read in part, .Resident is s/p fall day 2/3, no delay injury noted . Residents Affected - Few In an interview on 3/21/23 at 12:39 p.m. Resident #37's family member said Resident #37 flipped over backwards in the wheelchair and hit his head yesterday morning (3/20/23). She said two therapists picked Resident #37 up from the floor. She said the DON assessed Resident #37 approximately 30 minutes after the fall. In an observation and interview on 3/21/23 at 12:42 p.m. Resident #37 was lying in bed. He said he suffered pain in his left leg and foot from the fall and asked for pain medication every 15 minutes last night (3/20/23). Record review of Resident #37's care plan revised on 3/22/23 revealed the resident had an actual fall with no injury. The intervention was provided anti-tippers to wheelchair. In an interview on 3/22/23 at 1:38 p.m. CNA X said on yesterday 3/21/23 he transferred Resident #37 to his wheelchair, he went backwards and hit his head slightly on the wall. He said there was a slight error with the back safety wheels (anti-tippers) on Resident #37's wheelchair. He said the wheels were locked, but he noticed after the fall that the anti-tippers were positioned incorrectly, they were turned up instead of down. He said he did not recall being trained specifically on the special wheels in the back (anti-tippers) prior to the fall. He said he reported the fall immediately to the nurse. He said two therapists assisted him immediately after the fall and positioned Resident #37 upright. He said Resident #37 was screaming, frightened, and panicking and wanted to get up so they sat him upright, and the DON came to assess him. He said they normally did not move a resident after a fall prior to the nurse assessing because there could be a fracture, contusion, or something else could be wrong with the resident. In an interview on 3/23/23 at 12:13 p.m. COTA said on the day Resident #37 fell (3/21/23) he was in the room next door to the resident. He said the whole room shook and he heard a boom. He went to Resident #37's room and saw him lying down (on the floor). He said CNA X was in the process of trying to get Resident #37 up and he helped him sit him up. He said the nurse had not made it yet but as soon as they got him up, CNA X left to get the nurse. He said they normally wait for the nurse to assess the resident before picking them up to make sure there is no injury. He said they picked him up prior to a nurse assessment because it was a reactionary response, and he was in the wheelchair. In an interview on 3/24/23 at 12:01 p.m. the DON said she trained CNAs in the past on not moving a resident prior to the nurse assessment. She said the resident could have a fracture and would not want to add to the injury. She said she talked to the therapy department about it as well. In an interview on 3/24/23 at 2:14 p.m. the Administrator said the CNA did not pay attention and the anti-tippers were positioned up and the wheelchair did not support the resident. She said a nurse was supposed to assess the resident prior to moving to ensure there was no injury from head to toe. Record review of the Wheelchair Anti-tippers in-service dated 2/22/23 presented by the DON read in part, .Our main goal is patient safety. Before transferring resident to wheelchair, make sure brakes 676244 Page 6 of 14 676244 03/24/2023 Willow Creek Lodge 11830 Northpointe Boulevard Tomball, TX 77377

F 0689 Level of Harm - Minimal harm or potential for actual harm are locked and check for anti-tipper . anti tipper wheels should be facing down. The purpose of anti-tipper is to prevent wheelchairs from going over backwards or tipping backwards. It also serves as a stabilizer to prevent from flipping wheelchair backwards. During an event of a resident fall, staff are not to get resident up without a nurse present. Charge nurses to assess the resident from head to toe and for possible injury. Unless the charge nurse say it is okay to get resident up, then we can get resident up . Residents Affected - Few Record review of the facility's Accidents and Incidents policy dated July 2017 read in part, .All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator . 3. This facility is in compliance with current rules and regulations governing accidents and/or incident involving a medical device. 676244 Page 7 of 14 676244 03/24/2023 Willow Creek Lodge 11830 Northpointe Boulevard Tomball, TX 77377

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status for 1 of 2 residents (Resident #12) reviewed for nutrition. Residents Affected - Few The facility failed to ensure Resident #12's tube feeding order was entered correctly. Resident #12 was receiving feeding over 20 hours instead of 22 hours as verbally ordered by the Physician. This failure could place residents in the facility at risk of not having their nutritional needs addressed and/or met. Findings included: Record review of Resident #12's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnosis included gastrostomy status (an opening from the stomach to the outside of the abdomen that can be used for feeding), mild protein-calorie malnutrition, deaf non speaking, and hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) following cerebral infarction (stroke). Record review of Resident #12's quarterly MDS assessment dated [DATE] revealed her cognitive skills for daily decision making was severely impaired. She received 51% or more total calories through a feeding tube. Record review of Resident #12's care plan dated 10/19/22 revealed she required tube feeing related to dysphagia (a condition with difficulty in swallowing food or liquid). Her intervention was to administer g-tube feedings as ordered. Record review of Resident #12's Progress Note dated 3/17/23 written by RN Y read in part, .Resident arrived at facility at 7:30 p.m. on stretcher with RP at her bedside. Per report, resident is NPO, on continuous feeding (Glucerna 1.2) rate 45 cc/hr . Record review of Resident #12's Order Summary Report for March 2023 revealed orders for Glucerna 1.5 continuous at 45 mL for 22 hours, order date 3/23/23; Resident will be disconnected from 10:00 a.m. 12:00 noon of downtime for ADLs, therapy, activities, and quality of life, order date 3/23/23. Record review of Resident #12's Physician Orders dated 3/23/23 revealed Glucerna 1.5 continuous at 45 mL for 20 hours was discontinued on 3/23/23 at 2:41 p.m.; Resident will be disconnected 8 a.m. - 12 noon of downtime for ADLs, therapy, activities, and quality of life was discontinued on 3/23/23 at 2:47 p.m. Record review of Resident #12's Progress Note dated 3/24/23 written by the DON read in part, .RP was notified yesterday 3/23/23 at approximately 1:30 p.m. that resident was getting a total of 135 less calories daily since 3/18/23. The order says continuous feeding x 22 hours, and to stop feeding at 10 a.m. and restart at 12 noon. The eMAR stop time was mistakenly entered at 8 a.m. RP was understanding during our discussion. Writer added that NP was also notified with new order to monitor weekly weight and RD consult, RP verbalizes understanding . Record review of Resident #12's Medication Administration Record for March 2023 revealed she was 676244 Page 8 of 14 676244 03/24/2023 Willow Creek Lodge 11830 Northpointe Boulevard Tomball, TX 77377

F 0692 disconnected from feeding at 8 a.m. and reconnected at noon daily from 3/19/23 to 3/23/23. Level of Harm - Minimal harm or potential for actual harm In an observation on 3/21/23 at 12:01 p.m. Resident #12 was lying in bed in her room. She motioned tear drops down both eyes and motioned pointed toward her mouth repeatedly. She pointed to tube feeding and rubbed her stomach. The tube feeding was off. Residents Affected - Few In an interview on 3/21/23 at 12:06 p.m. LVN V said Resident #12 was NPO and her feeding down time was from 8 a.m.-12 p.m. In an observation on 3/21/23 at 12:13 p.m. of Resident #12 she started to moan and pointed to her mouth and rubbed her stomach. Resident pointed to the formula and shook her hand. In an interview on 3/21/23 at 12:21 p.m. LVN V said she started Resident #12's feeding. She said the resident did not previously want the feeding and preferred to eat, but now the resident was accepting of the feeding and allowed her to turn the feeding on. In an interview on 3/23/23 at 3:12 p.m. the DON said she put the original feeding order in for Resident #12 and wrote to turn the feeding off at 8 a.m. and back on at 12 p.m. She said she did not know how that happened but just changed the order to run for 22 hours because it was supposed to be a 2-hour bowel rest, not 4 hours. She said she informed the MD who instructed her to do a RD consultation and monitor Resident #12's weights weekly. In an interview on 3/24/23 at 12:01 p.m. the DON said Resident #12 returned from the hospital (3/17/23) on 24 hours continuous feeding but knew there should be a gut rest. She said she verified the orders with the NP on 3/18/23 and he said to apply a 2-hour gut rest. She said she then put the order in wrong and did not find out about it until this Surveyor asked about it on Thursday 3/23/23. She said she notified the RD who said Resident #12 was receiving 135 calories less per day. In an interview on 3/24/23 at 12:17 p.m. the DON said they reweighed Resident #12 and she was 92.4 pounds. She said Resident #12 said she was hungry and there was a risk of malnutrition because Resident #12's BMI was low. She said there were normally more people who double checked the order including the nurse, ADON, and DON. In an interview on 3/24/23 at 12:37 p.m. the NP said it was ideal to give the resident a 2-hour bowel rest but did not think 4 hours was abnormal. He said the Dietitian would evaluate the resident to discuss the weight and ensure the caloric intake was appropriate. In an interview on 3/24/23 at 12:41 p.m. the Dietitian said she and the DON spoke about an error with Resident #12's feeding order. She said the feeding was supposed to run over 22 hours instead of 20 hours. She said Resident #12 was not receiving the required calories, protein, and fluids needed. She said the feeding order was corrected. In an interview on 3/24/23 at 2:14 p.m. the Administrator said there was a mistake in Resident #12's feeding order. She said she expected physician orders to be followed. She said the concern was fixed and taken to quality assurance. Record review of the facility's Medication Orders dated November 2014 read in part, .The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders . 4. Enteral orders - when recording orders for enteral tube feeding, specify the type of 676244 Page 9 of 14 676244 03/24/2023 Willow Creek Lodge 11830 Northpointe Boulevard Tomball, TX 77377

F 0692 feeding, amount, frequency of feeding . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 676244 Page 10 of 14 676244 03/24/2023 Willow Creek Lodge 11830 Northpointe Boulevard Tomball, TX 77377

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 12% based on 3 errors out of 25 opportunities, which involved 1 of 6 residents (Resident #25) reviewed for medication errors. Residents Affected - Few MA C administered Resident #231's Refresh Tears (eye drops) to Resident #25 and administered the wrong amount of Refresh Tears to Resident #25. MA C administered one Docusate (a stool softener) to Resident #25 instead of two as prescribed by the Physician. This failure could place residents at risk of not receiving the intended therapeutic benefits of prescribed medications. Findings included: Record review of Resident #25's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included vascular dementia (a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), constipation, and dry eye syndrome of bilateral lacrimal glands (a small almond-shaped organ that produces tears to moisten and protect the eye). Record review of Resident #25's quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15 which indicated intact cognition. She needed extensive assistance of two staff with ADL care. Record review of Resident #25's care plan dated 11/17/22 revealed she had constipation related to decreased mobility and pain. The interventions were to administer medications as ordered. Record review of Resident #25's Order Summary Report for March 2023 revealed orders for: Docusate 100 mg give 2 capsules in the morning for constipation, order date 8/23/19; Refresh tears solution 5% instill 2 drops in both eyes two time a day for dry eyes, order date 5/27/21. In an observation and interview on 3/22/23 at 8:32 am MA C prepared the following medication for Resident #25: Docusate 100 mg (1 tablet instead of 2 as prescribed by the doctor), Lubricating plus carboxymethylcellulose single use eye drops (Refresh Tears) that belonged to Resident #231, Citalopram 10 mg (1 tablet), Furosemide 20 mg (1 tablet), Carbidopa/levodopa 25 mg/100 mg (1 tablet), Meloxicam 7.5 mg (2 tablets), Potassium Chloride ER 10 meq (1 tablet), Acetaminophen 325 mg (2 tablets), Aspirin chewable 81 mg (1 tablet), and Senna plus 8.6/50 mg (1 tablet). MA C counted and said she had 11 pills in her medication cup. She entered Resident #25's room and administered the medication to Resident #25. She then administered 1 drop of Refresh Tears in each eye instead of 2 as prescribed by the doctor. In an interview on 3/22/23 at 8:38 a.m. MA C said she administered one drop for Refresh Tears in 676244 Page 11 of 14 676244 03/24/2023 Willow Creek Lodge 11830 Northpointe Boulevard Tomball, TX 77377

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few each eye for Resident #25, but she was supposed to administer two in each eye. She said she thought it was supposed to be two drops total. She said followed the MAR for the directions. She said she would administer an additional drop in each eye. She said according to the MAR she was supposed to administer 12 pills to Resident #25, but she only had 11. She said the resident was supposed to receive 2 docusate pills and she normally prepared 2. She said she thought she prepared 2 docusate pills. She said she was not supposed to use medication that belonged to another resident. She said the single use eye drops were house stock. In an interview on 3/23/23 at 3:16 p.m. the DON said she expected nursing staff to read the directions on the MAR and give the right amount to the resident because it is the doctor's order. She said MA C should have administered 2 drops per eye to Resident #25. She said eye drops were prescribed for dry eyes and the resident could have a little dryness. She said docusate was prescribed for constipation, and there was a risk of constipation. She said there was no borrowing of medication even if it was the same dosage, medication, or single use because it could cause the other resident to miss their medication due to a shortage. In an interview on 3/24/23 at 2:14 p.m. the Administrator said nursing staff were expected to follow the five medication rights which included the right dose and patient. She said staff were in serviced on checking the medication label and not borrowing medication from other residents. Record review of the facility's Administering Medications policy dated April 2019 read in part, .Medications are administered in a safe and timely manner, and as prescribed . 4. Medications are administered in accordance with prescriber orders . 9. The individual administering medications verifies the resident's identity before giving the resident his/her medications . 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . 26. Medications ordered for a particular resident may not be administered to another resident, unless permitted by State law and facility policy, and approved by the Director of Nursing Services. 676244 Page 12 of 14 676244 03/24/2023 Willow Creek Lodge 11830 Northpointe Boulevard Tomball, TX 77377

F 0922 Have enough backup water supply for essential areas of the nursing home. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and records reviewed, the facility failed to establish procedures to ensure that water is available to essential areas when there is a loss of normal water supply for 1 of 1 facility. Residents Affected - Many -The facility's emergency water supply consisted of 225 gallons (45, 5-gallon jugs) of water on hand for a census of 76 residents and 104 employees stored in a shed behind the building. This failure could place residents at serious risk for complications from dehydration and sanitation. Findings included: Observation of the emergency water supply on 03/23/2023 at 4:15 p.m. revealed there were 45, 5-gallons jugs of water for the emergency supply stored in the facility's shed located behind the building. During an interview on 03/24/2023 at 8:52 a.m., the Director of Food Services Manager (DFSM) said she had been the DFSM for about a year. She said they should have 1 gallon of water per person for 3 days (1 gallon of water x 3 days x (76 residents + 104 staff members=180 persons) = 540 gallons gallon of water) and currently had 45, 5-gallon jugs of water (225 gallons) on the premises. She said the facility probably needed about 679 total gallons of water for residents and staff. She said there was not an emergency water supply when she became the DFSM. She said due to budget constraints she could not order all the water at once. She said if there was a disaster, residents and staff would not get enough water. She said not having the required amount of water supply on hand could cause residents to get sick, become malnourished, and/or pass away. During an interview on 03/24/2023 at 3:40 p.m., the Administrator said she was responsible for ensuring the facility had the required amount of water as per regulation, and she had delegated the task to the DFSM. She said the facility should have 3 gallons of water per resident per day. She said she did not know how many gallons of water was on hand. She said if the facility needed more water, she would go to the store and buy more. She said residents would not be able to take their medications and/or stay hydrated if they did not have the required emergency water supply. Record review of the undated Emergency Preparedness Guidance from their local food vendor, read in part: 7. An emergency source of water needs to be identified. One gallon per person, per day, is essential and a minimum three-day supply should be on hand at all times. This includes residents, staff, families of residents, and families of staff who will be at the facility. Record review of the facility's Emergency Supplies Planning policy, revised August 2018, read in part: Supplies Assessment: 2. An adequate supply of emergency water .is maintained in appropriate quantities and in accordance with all applicable regulations to accommodate the needs of residents, staff members, and their 676244 Page 13 of 14 676244 03/24/2023 Willow Creek Lodge 11830 Northpointe Boulevard Tomball, TX 77377

F 0922 family members for emergency situations requiring evacuation or sheltering in place. Level of Harm - Minimal harm or potential for actual harm Sealed Emergency Water Supply: 1. Residents Affected - Many The facility maintains a minimum of 1 gallon of sealed emergency water per person for three days. This is the minimum amount designated for personal use/consumption and not for the essential functions of the facility. 2. The emergency water needs for personal consumption are calculated using the following equation: Calculation: (gallons) x (days) x (people) = gallons needed Gallons of water per person = 1 (recommended) Numbers of days = 3 recommended Number of people (staff + residents) = ____ Example: 1 (gallons) x 3 (days) x 200 (people) = 600 gallons needed. 676244 Page 14 of 14