Health inspection·December 15, 2022

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on observation, interview, and record review, the facility failed to establish a Grievance Policy that allowed residents to file a grievance anonymously and notified residents individually or through postings of filing a grievance. a. The facility failed to provide residents with a source to anonymously file a grievance. b. The facility failed to follow their own policy of maintaining a file of the results of all grievances investigated or reported for a minimum of three years from the issuance of the grievance decision. This failure could cause grievances to not be filed due to no assurance of anonymity and this could cause the facility to miss trending problems and grievances to be left unresolved. The findings included: Observation on 12/12/22 at 9:30 AM of the bullitin board revealed there was no way for residents to file an anonymous grievance. There was no grievance box or grievance forms available without requesting a form from facility staff In an interview on 12/12/22 at 10:03 AM 12/12/22 10:03 AM The social worker stated the facility does not keep a grievance log. She stated a grievance log was not necessary because she handles things when they come up and corrects the problem at that time. In an Interview on 12/12/22 at 3:43 PM the DON stated she was not aware a grievance log was not kept at the facility . She stated social worker is responsible for grievances. She stated she was new to the facility, but she would expect that a log with grievances and their resolutions was kept at the facility. She stated that this was what she was accustomed to in her prior places of employment. In an interview on 12/12/22 at1:00 PM the administrator stated the facility did not have a grievance log because they dealt with resident and family concerns immediately . He stated he could see that it might be a problem to not have documentation to support that a grievance had been acted upon and a resolution was reached. He also stated they do not have a box or a system in place for residents and family to file a grievance anonymously. In an interview on 12/13/22 at 2:30 PM with the resident council, the 8 members in attendance stated they did not know how to file a grievance, or who the grievance officer was. They stated they were unaware of the process of filing a grievance, or that they could file a grievance anonymously Page 1 of 12 676365 676365 12/15/2022 Willow Park Rehabilitation and Care Center 300 Crowne Point Blvd Willow Park, TX 76087

F 0585 . Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy titled Grievances/Complaints. with a revision date of 4/2017 revealed the following in part: Residents Affected - Some Policy Statement Residents and their representatives have the right to file grievances either orally or in writing. The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and or representative. Policy Interpretation and Implementation. 2. Resident's families and representatives have the right to voice or file grievances without fear of reprisal. 3. All grievances and or complaints or recommendations stemming from residents or resident groups concerning issues of resident care in the facility will be considered.,. Actions on such items will be to in writing, including a rationale for the response. 14. The results of all grievance files, investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision. 676365 Page 2 of 12 676365 12/15/2022 Willow Park Rehabilitation and Care Center 300 Crowne Point Blvd Willow Park, TX 76087

F 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. 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 that 5 (180, 70, 184, 185, 186) of 6 residents were seen by their physician every 30 days for the first 90 days and every 60 days thereafter. Residents Affected - Some The facility failed to ensure initial visits were conducted by a physician for residents 180, 70, 184, 185, and 186. This failure by the facility places residents at risk of not receiving needed services ordered by physicians. Findings include; Resident 180 a [AGE] year-old female admitted on [DATE], with the following diagnoses: Diabetes Type 2, COPD (Chronic Obstructive Pulmonary Disease), left abdominal wall wound status post I&D (Incision and Drainage) and wound vac placement, thoracic aortic aneurysm (bulge or ballooning) without rupture. Resident 180's initial provider visit was done on 12/7/22, by Nurse Practitioner 1 (NP1), followed by NP2 on 12/9/22, and was then seen by DR1 on 12/12/22. Resident 70 a [AGE] year-old male admitted on [DATE], with the following diagnoses: acute urinary tract infection, essential hypertension, sepsis, Diabetes mellitus. Resident 70's initial provider visit was done on 11/16/22 by NP1, followed by DR1 on 11/21/22. Resident 186 a [AGE] year-old male admitted on [DATE], with the following diagnoses: Influenza A, acute respiratory failure with hypoxia (low oxygen content in bloodstream), primary hypertension. Resident 186's initial provider visit was done on 12/2/22, by NP3, followed by DR2 on 12/6/22. Resident 184 a [AGE] year-old female admitted on [DATE], with the following diagnoses: syncope (fainting), closed fracture of right ankle, pneumonia. Resident 184's initial provider visit was done on 12/9/22, by NP3, followed by DR2 on 12/13/22. Resident 184 interviewed on 12/13/22, at 2:41 PM said her first visit was done by a nurse practitioner two days after she was admitted to the facility, and she did not see the doctor until today (12/13/2022) two days before her expected discharge. Resident 185 a [AGE] year-old female admitted on [DATE], with the following diagnoses: congestive heart failure, depression, Diabetes mellitus essential hypertension and acute renal failure. Resident 185's initial provider visit was done on 12/2/22, by NP3, followed by DR2 on 12/6/22. Director of Nurses (DON) interviewed on 12/15/22, at 11:18 AM when asked about timeliness of physician visits said that DR1 only comes to the facility on Mondays, while DR2 comes in on certain days of the week. 676365 Page 3 of 12 676365 12/15/2022 Willow Park Rehabilitation and Care Center 300 Crowne Point Blvd Willow Park, TX 76087

F 0712 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Administrator interviewed on 12/15/22, at 3:47 PM said he thinks the doctors only come in on certain days such as, DR2 comes in on Sunday and Tuesday and DR1 on Monday. Administrator said the physicians are supposed to sign off on new admissions within 72 hours but is not sure about anything else. Record review of a facility policy titled Operational Policy and Procedure Manual for Long-Term Care; Physician Services revised April 2015. Page 5 Resident Visits 1, The attending Physician will visit residents in a timely fashion, consistent with applicable state and federal requirements, and depending on the individual's medical stability, recent and previous medical history, and the presence of medical conditions or problems that cannot be handled readily by phone (see policy on Resident visits). a. The visit schedule will be at least every 30 days for the first 90 days after admission, and then at least every 60 days thereafter. b. After the first 90 days, a Nurse Practitioner or other mid-level practitioner under the Physician's supervision can make alternate scheduled visits, unless otherwise restricted by regulations. 676365 Page 4 of 12 676365 12/15/2022 Willow Park Rehabilitation and Care Center 300 Crowne Point Blvd Willow Park, TX 76087

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and interview the facility failed to ensure that the daily nurse staffing was posted as required. Residents Affected - Many The facility failed to update the daily staffing information posting. This failure could place the residents, families, and visitors at risk of not having access to information regarding the daily nurse staffing data and facility census. Findings included: Observation on 12/12/22 at 9:30 AM, revealed the daily staffing pattern was posted on the window of the ADON office across from hall 1 and 2 nurse's station. The staffing posting did not include the following required information: resident census for the beginning of the shift for which it was posted, and the staffing posting was completed for all three shifts and not updated within 2 hours of the beginning of each shift to reflect the total number of licensed nurses, unlicensed staff, CNAs, or HAs scheduled, the actual hours scheduled, or the actual hours worked. Observation on 12/12/22 at 4:00 PM, revealed the daily staffing pattern was posted on the window of the ADON office across from hall 1 and 2 nurse's station. The staffing posting did not include the following required information: resident census for the beginning of the shift for which it was posted, and the staffing posting was completed for all three shifts and not updated within 2 hours of the beginning of each shift to reflect the total number of licensed nurses, unlicensed staff, CNAs, or HAs scheduled, the actual hours scheduled, or the actual hours worked. Observation on 12/13/22 at 10:00 AM, revealed the daily staffing pattern was posted on the window of the ADON office across from hall 1 and 2 nurse's station. The staffing posting did not include the following required information: resident census for the beginning of the shift for which it was posted, and the staffing posting was completed for all three shifts and not updated within 2 hours of the beginning of each shift to reflect the total number of licensed nurses, unlicensed staff, CNAs, or HAs scheduled, the actual hours scheduled, or the actual hours worked. Observation on 12/13/22 at 4:00 PM, revealed the daily staffing pattern was posted on the window of the ADON office across from hall 1 and 2 nurse's station. The staffing posting did not include the following required information: resident census for the beginning of the shift for which it was posted, and the staffing posting was completed for all three shifts and not updated within 2 hours of the beginning of each shift to reflect the total number of licensed nurses, unlicensed staff, CNAs, or HAs scheduled, the actual hours scheduled, or the actual hours worked. During interview on 12/13/22 at 3:00 PM, the DON stated the ADON was responsible for the staffing and staffing posting. During interview on 12/13/22 at 3:30 PM, the ADON stated, she was responsible for the staffing posting, but was not aware of all the information the staffing posting should contain. she further revealed, she was unable to produce 18 months of prior staffing postings. During interview on 12/14/22 at 10:40 AM, the Administrator stated, the Nursing department is responsible for nursing staffing and postings. 676365 Page 5 of 12 676365 12/15/2022 Willow Park Rehabilitation and Care Center 300 Crowne Point Blvd Willow Park, TX 76087

F 0732 Record Review of the facility's policy Staffing, revised July 2016, revealed the following [in part]: Level of Harm - Potential for minimal harm Policy Statement: Our center provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the center assessment. Residents Affected - Many 6. Staff levels for direct care staffing is updated within 2 hours of each shift and posted in a public area. 676365 Page 6 of 12 676365 12/15/2022 Willow Park Rehabilitation and Care Center 300 Crowne Point Blvd Willow Park, TX 76087

F 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents receive drinks including water and other liquids consistent with need and preference and sufficient to maintain hydration for 7 (Resident #'s 15. 44, 62, 28 67,and 29 ) of 8 residents reviewed for hydration. The facility did not provide routine ice and water in resident #15, 44, 1, 62, 28, 67, and 29's rooms. These deficient practices could place residents at-risk for thirst, dehydration, UTIs, and decreased quality of life. Findings included: Resident #15 Record review of Resident #15's Quarterly MDS Resident assessment dated [DATE] revealed she was an [AGE] year-old female admitted to the facility on with active diagnoses of Alzheimer's, diabetes, and renal failure. She had severe cognitive impairment, had a BIMS score of 4 and required supervision to eat or drink. Observation of Resident # 15 on 12/12/22 at 10:23 AM revealed she was in her bed sleeping with her bed in low position . She was able to respond occasionally to simple greetings, but she was not able to follow the flow of the conversation and was not Interview able. She had no water picture or glass in her room . Observation of Hall 2 on 12/12/22 at 10:23 AM revealed there was 1 CNA and one HA on hall 2 to pass water for 28 residents. Observation of Resident #15 on 12/12/22 at 3:59 PM revealed she was asleep in her bed. There was no water pitcher in her room, nor a cup of ice or water. Observation on 12/13/22 at 10:00 AM revealed no water pitcher with water and ice in Residents #15's room. There was one half 8 0z glass of water with no ice in it on the bedside table. Resident #44 Review of Resident #44's Quarterly MDS assessment dated [DATE] revealed she was an [AGE] year-old female admitted to the facility on [DATE] with an active diagnosis of Alzheimer's, dementia, diabetes, and hypertension. Resident #44 had a BIMS of 13 and was able to eat and drink unassisted. Observation and interview of Resident #44 on 12/12/22 at 10:00 AM revealed there was no ice and water in her drinking pitcher . Resident #44 stated if she gets water, she is usually the one to get it. She stated she just gets her water out of the bathroom lavatory. She stated there was an ice cart that sits in the hallway by a sitting area that has ice in it. She stated she has told Nurses about the aides not passing ice water, but she doesn't remember which ones or when she last complained. 676365 Page 7 of 12 676365 12/15/2022 Willow Park Rehabilitation and Care Center 300 Crowne Point Blvd Willow Park, TX 76087

F 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an observation and interview on 12/12/22 at 4:02 PM Resident #44 was in her wheelchair in her room. She stated she had not seen anyone pass ice on hall 2 or to her room. She stated her picture was empty again. Observation revealed the resident's drinking pitcher had no water or ice. In an observation and interview on 12/14/22 09:05 AM Resident #44's breakfast tray in room. Stated she had just gotten up. No water in water pitcher in room. There was 1/2 bottle of a soft drink that was warm to touch on her bedside table with an old banana peel and her breakfast tray with approximately a 6 oz glass of orange juice that was covered and 240 cc of coffee in a cup on her breakfast tray. She Stated these were her usual liquids she received on her tray for breakfast. Resident #1 Record review of Resident #1's Annual MDS dated [DATE] revealed she was a [AGE] year-old female admitted to the facility on [DATE] with active diagnoses of Alzheimer's congestive heart failure and hypertension . The MDS assessment indicated she had a BIMS score of 11 which indicated moderate cognitive impairment and required staff supervision or cueing to eat. Observation of Resident #1 on 12/12/22 at 11:24 AM revealed she was in her room in her wheelchair in the supine There was no water pitcher by her bed. She stated: No, I don't have any water they don't keep water around . She stated: I can't understand why we can't have pure, clean water. Observation of Resident #1 on 12/12/22 at 3:53 PM revealed she was in bed lying flat. No pitcher with water and ice was in her room . There was an 8 oz glass that was half full of water and with no ice in the glass. An observation and interview on 12/14/22 at 09:54 AM revealed Resident #1 had one half glass of juice on her table. She stated she stretches it out to make it last because only one lady brings water regularly when she works She stated she did not know their names. She stated they are supposed to have a pitcher of water and ice in the rooms, but they don't do it that way. She stated they just answer call lights at their convenience. She stated she has sat on the toilet 45 minutes or longer a many a time just waiting for assistance. Resident #62 Record review of Resident 62's Quarterly MDS dated [DATE] revealed he was a [AGE] year-old male admitted to the facility on [DATE] with active diagnoses of renal insufficiency, anemia, and hypertension. The MDS assessment indicated he had a BIMS score of 10 which indicated moderate cognitive impairment and required supervision or cueing and assist of one person to eat or drink. In an interview on 12/13/22 at 11:46 AM Resident #62 stated he has trouble getting fluids other than at mealtime. He stated they do not pass ice and water regularly. He stated all the fluids he gets regularly is with his meals. He states he has had 2 or three water pitchers since he has been here which came from the hospital, and they get taken up if he goes to the hospital and he doesn't get them back. He stated he has to ask for fluids, but he hasn't complained about anyone because he knows the aides are busy and work hard. He stated he does not know their names. Resident #28 Record review of Resident 28's admission MDS dated [DATE] revealed she was a [AGE] year-old female 676365 Page 8 of 12 676365 12/15/2022 Willow Park Rehabilitation and Care Center 300 Crowne Point Blvd Willow Park, TX 76087

F 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some admitted to the facility on [DATE] with active diagnoses Alzheimer's, diabetes, and arthritis. The MDS assessment indicated she had a BIMS score of 7 which indicated moderate cognitive impairment and required supervision or cueing and assist of one person to eat or drink In an interview and observation on 12/14/22 resident #28's husband, who is her roommate, stated water is not passed every shift. He stated resident's get fluids on their tray at lunch, but you have to ask for water to get it. Then it might take a while, or sometimes they answer the light and don't come back. Resident #67 Record review of Resident 67's Quarterly MDS date 9/06/22 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with active diagnoses of CVA (stroke) , aphasia (inability to speak), dementia ,hemiplegia (inability to move one side of the body. The MDS indicated she was unable to complete the BIMS but had a short- and long-term memory problem and required extensive assistance of one person to eat or drink. In an interview and observation on12/12/22 03:42 PM Resident #67's Husband Stated They will bring water if he asks them to. He states he visits daily and stays most of the day. Resident #67 had no water pitcher, and no water at her bedside. Resident was unable to speak. Husband stated he will go and get fluids for Resident #67 when he is there. He stated Resident #67 requires assistance with eating and drinking and is unable to drink fluids without assistance of another person. Observation at that time revealed Resident #67 had no water pitcher and no water at bedside. Resident #29 Record review of Resident 29's Quarterly MDS date 9/06/22 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with active diagnoses of CVA (stroke) , aphasia (inability to speak), dementia ,hemiplegia (inability to move one side of the body. The MDS indicated she was unable to complete the BIMS but had a short- and long-term memory problem and required extensive assistance of one person to eat or drink. Observation on 12/14/22 at 12:31 PM there was no water in Resident #29's room a small empty glass was sitting Resident #29's bedside table. Interview with the ADON on 12/15/22 at 11:17AM revealed the CNA'S and HAs been responsible for passing ice water each shift. She stated the ADON's, and the charge nurses were responsible for monitoring to see that water and ice had been passed each shift If a resident was non-verbal, they should be offered fluids when the nurses or aides go into the room to provide care. She stated insufficient fluid intake could lead to dehydration and urinary tract infection. Interview with DON on 12/15/22 at 2:24 PM revealed her expectation for residents maintaining sufficient hydration was to have water pitchers by the bedside and to encourage water every shift unless they were on a fluid restriction. She said for residents with dementia, they included water and fluids in activities on the secured units. The DON was asked if there should always be water available in a resident's room. She responded unless they were on fluid restriction or thickened liquids. The DON said a lack of water could result in urinary tract infection and dehydration. Review of the facility policy titled Hydration Clinical Protocol, dated revised 2017 revealed the 676365 Page 9 of 12 676365 12/15/2022 Willow Park Rehabilitation and Care Center 300 Crowne Point Blvd Willow Park, TX 76087

F 0807 following in part: Level of Harm - Minimal harm or potential for actual harm Treatment /Management Residents Affected - Some 2. The staff will provide supportive measures such as supplemental fluids and adjusting environmental temperature where indicated. 676365 Page 10 of 12 676365 12/15/2022 Willow Park Rehabilitation and Care Center 300 Crowne Point Blvd Willow Park, TX 76087

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed. Residents Affected - Many 1. The floors were soiled with food particles and grease beneath the appliances and stainless-steel shelf units throughout the kitchen. 2. The stainless-steel shelf units were soiled with spilled spices, food crumbs, and dried liquids. 3. The appliance surfaces were soiled with dust and grease build-up. These failures could place residents at risk for foodborne illness and a decline in health status. The findings include: Observations on 12/12/22 at 8:40 AM, during the initial tour of the facility kitchen, revealed the following: - the exterior surface of the ice making machine was soiled with dust on the top and dried food splatters on the door surface. - water was on the floor in front and under the ice machine. - the floor was soiled with food debris and grease beneath shelves and appliances throughout the kitchen. - stainless steel shelf units were soiled with food crumbs and dust throughout the kitchen. - interior surfaces of the ovens and the convection oven were soiled with grease and spilled food debris. Observation on 12/12/22 at 9:30 AM revealed daily temperature logs dated December 2022, used for the walk-in refrigerator and freezer units and the small refrigerator for condiments in the food preparation area, were posted in the kitchen. No cleaning schedules were observed. In an interview on 12/13/22 at 9:40 AM, Dietary Aide A stated she had not seen or used a cleaning schedule or any type of cleaning checklist. She stated she used a solution of water and peroxide disinfectant and a rag to wipe down counters and clean the beverage station. Dietary Aide A stated she had an unwritten cleaning schedule. She stated she did not know what the dietary staff did at night. During an observation and interview on 12/13/22 at 10:50 AM, the Dietary Manager went to the front of the kitchen to the area where binder notebooks were stored on a shelf. The binder notebooks contained documented food temperature logs, freezer and refrigerator temperature logs, and menus. There were no documented cleaning schedule worksheets found in the binder notebooks. The Dietary Manager stated he did not know the last time the cleaning schedule worksheets were used. He stated he would provide a copy the facility's policy and procedure for cleaning and use of schedules. 676365 Page 11 of 12 676365 12/15/2022 Willow Park Rehabilitation and Care Center 300 Crowne Point Blvd Willow Park, TX 76087

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the facility's dietary Policy and Procedure Manual, Sample Cleaning Schedule, not dated, revealed the policy and procedure listed cleaning to be completed after each use, daily, weekly, monthly, twice per month, and cleaning tasks to be referred to housekeeping (e.g., walls, ceilings, doors, fixtures, and waxing floors). The Sample Daily Cleaning Schedule Form had columns for items (blank/no items listed - to be written in by staff), responsible party, initials and dates, columns for the days of the week Monday through Sunday, and a column for the Director of Food and Nutrition Services to initial after checking to ensure the work was done satisfactorily. Review of the U.S. Food and Drug Administration, 2017 Food Code, reflected: Preventing Contamination from the Premises 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location. (2) Where it is not exposed to splash, dust, or other contamination . Storing 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLEUSE ARTICLES shall be stored: (1) In a clean, dry location. (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted. 6-501.111 Controlling Pests. The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: (A) Routinely inspecting incoming shipments of FOOD and supplies; (B) Routinely inspecting the PREMISES for evidence of pests; (C) Using methods, if pests are found, such as trapping devices or other means of pest control as specified under §§ 7-202.12, 7-206.12, and 7-206.13; and (D) Eliminating harborage conditions. 676365 Page 12 of 12