Health inspection·February 15, 2024

F 0641 - Quarterly assessment dated [DATE] documented a weight of 149 pounds; no weight loss/gain. Level of Harm - Minimal harm or potential for actual harm Review of the facility's resident weight variance report, dated February 2024, revealed Resident #2 weighed 172.1 pounds on 08/08/2023 and weighed 141 pounds and 02/02/2024, which was an 18.07 % weight loss in 6 months. Residents Affected - Few Review of Resident #2's comprehensive care plan revealed a care plan dated as initiated 1/11/2022 that documented the resident had planned/expected weight loss related to diuretic use for pulmonary edema with Lasix started. The care plan documented additional unplanned weight loss was noted related to difficulty with chewing; the resident did not want puree texture. 10/2/23 - weight 154.6 pounds using the lift. During an interview and record review on 2/15/2024 at 2:17 PM, MDS Coordinator A stated there was not a facility policy and procedure for the accurate completion of MDS assessments. She stated she used RAI manual for guidance. She stated she had a Corporate MDS Consultant who reviewed the residents' electronic health records and MDS assessments. MDS Coordinator A stated she had not realized Resident #2 had lost weight. She stated the MDS was supposed to populate the current weight but did not show the prior weight. MDS Coordinator A reviewed Resident #2's MDS assessments. She stated the quarterly assessment dated [DATE] would have flagged for a 10% weight loss in 6 months. She stated she did not select weight loss on the assessment. MDS Coordinator A stated she would do an MDS correction assessment for Resident #2. She stated the new DON was setting up a weight monitoring system. 2.Review of Resident #14's admission Record, dated 2/15/2024, revealed an [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included cerebral infarction (stroke), hemiplegia and hemiparesis following cerebral infraction affecting right dominate side (paralysis), aphasia (A comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to the specific area in the brain) following cerebral infraction, and hypertension (high blood pressure). Review of Resident #14's MDS assessments revealed a height of 65 and the following: Annual assessment dated [DATE] documented a weight of 135 pounds; no weight loss/gain. Review of Resident #14's comprehensive care plan revealed a care plan dated as initiated 12/18/2023 that documented the resident had planned/expected weight loss and to increase DiabetiSource from 3 cans a day to 5 cans a day. During an interview and record review on 2/15/2024 at 12:34 PM, MDS Coordinator A stated It was her responsibly to complete the MDS assessments for the long-term care residents. She said there was not a facility policy and procedure for the accurate completion of MDS assessments. She stated she used RAI manual for guidance. She said, It was missed. She said a potential negative outcome would that it could possibly be detrimental to the resident if it was not caught. In an interview with the DON on 02/15/2024 at 12:56 PM, she said the MDS Coordinator was responsible for completed the MDS assessments. She said a potential negative outcome of the failure would be the resident would not receive the needed treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676365 If continuation sheet Page 2 of 11 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 676365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Park Rehabilitation and Care Center 300 Crowne Point Blvd Willow Park, TX 76087 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 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. Based on interviews and record reviews, the facility failed to notify the state mental health authority promptly after a significant change in the mental condition for 1 of 8 residents (Resident #51) reviewed for mental illness, intellectual disability, or developmental disability. The facility failed to complete a PL1 with addendum form -1012 when Resident # 51 received a new diagnosis for Bi-Polar Disorder, current episode manic severe with Psychotic features added on 11/18/2023. This failure placed resident at risk of mental health needs not being met. The findings included: A record review of Resident # 51's face sheet dated 2/14/24 revealed initial admission was 6/26/23. A diagnosis list that included Bipolar Disorder, Current Episode Manic Severe with Psychotic Features (diagnosis date 10/20/23). A record review of PASARR Level 1 (PL1) screening, dated 6/26/23, indicated Resident # 51 had no indication of mental illness. No PASARR Level II (PE) Screening or Form-1012 (mental illness/Dementia Resident Review) was found in the clinical record. A record review of Resident #51's of the last care plan updated 12/11/23, with a Problem start date of 10/20/23, indicated under the Focus category: Resident is at-risk for complications/mood issues related to depression, anxiety, PTSD, Bipolar Disorder-Interventions (in-part) Administer medications as ordered. Monitor/document for side effects and effectiveness. Date initiated 10/20/2023. During an interview, on 02/14/2024 at 3:30 PM, regarding Resident # 51's PL1's and PE's and completing the form 1012, MDS Coordinator A stated she was responsible for long term skilled resident's and entering them into the long-term care portal. She stated she did not complete a new PL1, PE or form 1012 on Resident # 51. The only PL1 completed was done on 06/26/23. She stated she just missed doing another PL1 on 10/20/23 and that she should have done a PE on 11/18/23 after new diagnosis of BIPOLAR DISORDER, CURRENT EPISODE MANIC SEVERE WITH PSYCHOTIC FEATURES. She acknowledged that there should be a positive PL1, and PE should have been completed. She stated she was familiar with this requirement. She stated the forms had been missed by an oversight on her part and acknowledged the failure. In an interview on 2/15/24 at 10:00 AM, the DON stated she had just started at the facility for a week. She said the MDS Nurse would be responsible for monitoring residents for changes in resident status related to ID/MI as far as she knew. The facility uses the RAI manual as their policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676365 If continuation sheet Page 3 of 11 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 676365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Park Rehabilitation and Care Center 300 Crowne Point Blvd Willow Park, TX 76087 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 1 of 2 residents (Resident #57) reviewed for ADLs. Residents Affected - Few The facility failed to provide showers consistently for Resident #57. This failure could place residents at risk for poor personal hygiene and a decline in their quality of life and health status. Findings included: Record review of Resident #57's Face Sheet, dated 02/15/24 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with a latest return date of 10/26/23 with the following diagnoses: cerebral infarction (stroke), contracture of muscle (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen.) of right shoulder, right upper arm, right forearm, right hand and left hand. Review of Resident #57's quarterly MDS dated [DATE] revealed the resident was admitted to the facility on [DATE] his bathing was coded as dependent. Review of Resident #57's Care Plan last completed on 02/05/24 revealed he had ADL self-care performance deficit related to impaired balance and limited mobility. He required the assistance of 1 staff. In an interview on 02/13/24 at 9:34 AM, Resident #57 stated he was getting baths on Tuesday and Thursdays but not on Saturdays. He did not know why he was not getting baths on Saturdays. In an interview and record review with the DON on 02/15/24 at 2:28 PM, Resident #57's shower sheets were reviewed from January 2024 to present date of 02/15/24, revealed the resident did not receive any baths on Saturdays during the review period. There was no other documentation as to why the resident did not receive showers on Saturdays. The DON said she did not know why Resident #57 was not receiving baths on Saturdays. She said a potential negative outcome would be skin issues would not be identified. Record review of the facility policy Resident Showers, dated as revised 01/01/24, revealed the following [in part]: Policy: It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. Policy Explanation and Compliance Guidelines: 1. Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676365 If continuation sheet Page 4 of 11 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 676365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Park Rehabilitation and Care Center 300 Crowne Point Blvd Willow Park, TX 76087 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the planned menus were followed and prepared according to the weekly menu for 3 of 4 supper meals planned during the 4 day survey time frame. A menu substitution was hand-written on the Week at a Glance Fall / Winter Menu 2023 -2024, Week 1 for Monday's 2/12/24 supper meal. The substitution was not recorded on the Menu Substitution Sheet. The Week at a Glance Fall / Winter Menu 2023 -2024, Week 1 for Wednesday's 2/14/24 supper meal was partially substituted with the menu for Thursday's 2/15/24 supper meal due to the main entrée of chicken and dumplings not being prepared according to the planned menu for 2/14/24. This failure placed the residents at risk for not receiving meals adequate to meet their nutritional needs and a decline in nutritional health status. The findings included: Review of the Week at a Glance - Fall / Winter Menu 2023-2024, Week 1, revealed a hand-written substitution at the bottom of the page for the Monday 2/12/24 supper meal. The menu of beef stroganoff, Italian green beans, and dinner roll were being substituted for potato crusted [NAME], au gratin potatoes, and green peas with sauteed onion. Review of the Week at a Glance - Fall / Winter Menu 2023-2024, Week 1, revealed the following planned menus: Wednesday Supper 2/14/24: chicken and dumplings; tossed salad with dressing; cornbread with margarine; warm iced cinnamon roll; milk; beverage of choice; water. Thursday Supper 2/15/24: BBQ riblette; potato salad; fried okra; blushing pears; bread slice with margarine; milk; beverage of choice; water. Review of the Menu Substitution Sheet Sample Form revealed entries for the scheduled food item on 2/14/24, substitute, reason for substitution, and employee signature, dated 2/14/24 as follow: - Chicken and dumplings were substituted with BBQ riblettes due to the chicken and dumplings not being prepared; signed by [NAME] B. - Salad was substituted with beets due to switching days; signed by [NAME] B. - Chicken and dumplings were substituted with potato salad due to switching days; signed by [NAME] B. There were no other menu item substitutions recorded on the Menu Substitution Sheet Sample Form. There was no documentation for the hand-written menu substitution for Monday's Supper 2/12/24 menu on the Week at a Glance Menu. In an interview on 2/14/24 at 3:55 PM, [NAME] B stated she was substituting the menu for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676365 If continuation sheet Page 5 of 11 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 676365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Park Rehabilitation and Care Center 300 Crowne Point Blvd Willow Park, TX 76087 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Wednesday's 22/14/24 supper meal with the menu for Thursday's 2/15/24 supper meal. [NAME] B stated the chicken and dumplings needed to be made from scratch. She stated she had all the ingredients to make them. She stated the Dietary Manager usually got things ready for her, but the Dietary Manger had not been there that day due to having appointments all day. [NAME] B stated the substituted menu would be BBQ riblettes, potato salad, sliced red beets, and cinnamon rolls. She stated she could not prepare fried okra as planned on Thursday's 2/15/24 supper menu due to the bottom of the deep fryer leaking and needing to be welded. She stated the fryer unit was taken out over 1 week ago and should be ready to be brought back soon. In an interview on 2/14/24 at 4:02 PM, [NAME] B stated she would write down the substitution of chicken and dumplings with BBQ riblettes. The cook proceeded to take a spiral notebook from a shelf, open it, and write down chicken and dumplings and BBQ riblettes on a blank page of lined paper. She stated the current cycle of menus started in January 2024. In an interview on 2/14/24 at 5:10 PM, [NAME] B stated she had made the potato salad with potatoes that were canned and pre-cooked. She stated the sliced beets were canned and pre-cooked and were to be served cold as a substitute for the menu vegetable. [It was not clear what menu vegetable was being substituted.] In an interview and observation on 2/15/24 at 5:20 PM, the Dietary Manager stated she had past food substitution logs. She proceeded to look in a desk drawer in her office and did not locate the past logs. Review of the facility's policy and procedure for Menu Planning, dated 2013, revealed the following [in part]: Policy: Nutritional needs of individuals will be provided in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences (adjusted for age, gender, activity level and disability) through nourishing, well-balanced diets, unless contraindicated by medical needs. Procedure: 1. Menu planning is completed by the facility for at least two weeks in advance of need and menus are kept on file for a minimum of 90 days . Regular and therapeutic menus are written to provide a variety of foods served on different days of the week, adjusted for seasonal changes, and in adequate amounts at each meal to satisfy recommended daily allowances . 6. Temporary changes in the menu are noted on the menu substitution sheets and posted for the staff's benefit . Review of the facility's policy and procedure for Menu Substitutions, dated 2013, revealed the following [in part]: Policy: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676365 If continuation sheet Page 6 of 11 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 676365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Park Rehabilitation and Care Center 300 Crowne Point Blvd Willow Park, TX 76087 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 0803 Level of Harm - Minimal harm or potential for actual harm To provide a substitute when an uncontrollable situation (i.e. inventory emergency) has temporarily made the item unavailable; decisions on menu substitutions will be made after discussion with the food service manager whenever possible. Procedure: Residents Affected - Some 1. Kitchen staff will consult with the food service manager or designee on any needed menu substitutions . 3. All changes to the menu will be recorded on the Menu Extension Sheets and the Menu Substitution Sheet .The date, menu item, substitution and reason for the substitution will be recorded on the Menu Substitution Sheet . 5. Records of menu substitutions are retained for 12 months. These records should be reviewed periodically by the food service manager . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676365 If continuation sheet Page 7 of 11 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 676365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Park Rehabilitation and Care Center 300 Crowne Point Blvd Willow Park, TX 76087 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to serve food at safe and appetizing temperatures during observation of the preparation of one of one meal. Residents Affected - Some The planned Wednesday supper menu for 2/14/24 was substituted and potato salad and sliced red beets were not prepared in advance to ensure they were served at 41 degrees F or below. This failure placed residents at risk for receiving food that was not at a palatable temperature and foodborne illness. The finding included: Review of the Week at a Glance - Fall / Winter Menu 2023-2024, Week 1, revealed the following planned menus: Wednesday Supper (2/14/24): chicken and dumplings; tossed salad with dressing; cornbread with margarine; warm iced cinnamon roll; milk; beverage of choice; water. Thursday Supper (2/15/24): BBQ riblette; potato salad; fried okra; blushing pears; bread slice with margarine; milk; beverage of choice; water. Review of the Menu Substitution Sheet Sample Form revealed entries for the scheduled food item, substitute, reason for substitution, and employee signature, dated 2/14/24 as follow: - Chicken and dumplings were substituted with BBQ riblettes due to the chicken and dumplings not being prepared; signed by [NAME] B. - Salad was substituted with beets due to switching days; signed by [NAME] B. - Chicken and dumplings were substituted with potato salad due to switching days; signed by [NAME] B. Observation on 2/14/24 at 4:30 PM revealed [NAME] B was preparing the mechanically altered meat. The cook placed the mechanical ground meat in a stainless steel pan and placed it on the steam table. She checked the temperature of the mechanical meat using a digital thermometer and it was measured at 120 degrees F. She placed the pan in the oven to reheat it. Observation on 2/14/24 at 4:55 PM revealed [NAME] B poured potato salad from a large stainless steel bowl into a rectangular stainless steel pan and placed it in a steam table well filled with ice. Observation on 2/14/24 at 5:02 PM revealed [NAME] B measured the food holding temperatures using a digital thermometer and alcohol prep pads to sanitize it. The warm food item temperatures were measured above 140 degrees F. The cold food items were not held at 41 degrees or below as follow: puree potato salad was 59.4 degrees F; puree beets were 57 degrees F; sliced beets were 61.7 degrees F; and the regular consistency potato salad was 61.1 degrees F. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676365 If continuation sheet Page 8 of 11 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 676365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Park Rehabilitation and Care Center 300 Crowne Point Blvd Willow Park, TX 76087 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 0804 Level of Harm - Minimal harm or potential for actual harm In an interview on 2/14/24 at 5:10 PM, [NAME] B stated she had made the potato salad first thing when she arrived at work that afternoon and had placed it in the refrigerator. She did not specify the time the potato salad was made. She stated the potatoes were canned and pre-cooked. [NAME] B stated the potato salad needed to be made the day before serving. The cook stated the sliced beets were canned and pre-cooked and were to be served cold as a substitute for the menu vegetable. Residents Affected - Some In an interview on 2/15/24 at 5:20 PM, the Dietary Manager stated no residents had been ill due to eating the potato salad served for the supper meal the previous day. Review of the facility policy and procedure for Food Temperatures, dated 2013, revealed the following [in part]: Policy: The temperatures of the food items will be taken and properly recorded for each meal. Procedure: 1. All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees F. Take temperatures often to monitor for safe food holding temperatures ranging at or below 41 degrees F for cold foods; and at or above 135 degrees F for hot foods . 2. All cold food items must be maintained and served at a temperature of 41 degrees F or below . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676365 If continuation sheet Page 9 of 11 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 676365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Park Rehabilitation and Care Center 300 Crowne Point Blvd Willow Park, TX 76087 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 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, in that: Residents Affected - Some The top exterior surface of the ice machine was soiled with dust build-up and had a plastic ice scoop on it without being in a protective holder. A stainless steel shelf was soiled with spilled spices. Cooking utensils and pans were suspended in the air from a frame and their sanitized food surfaces were exposed to the air. The nonperishable food storage room had a bulk storage container with brown sugar with a plastic scoop in it and an opened package of waffle mix had been placed in a resealable plastic bag but was not labeled or dated. The door to the walk-in refrigerator was left open during the evening meal preparation on 2/14/24. The dishwasher machine temperature log had water temperatures and sanitizer level recorded prior to being measured on 2/14/24. This failure placed residents at risk for decline in nutritional health status and foodborne illness. The findings included: Observations on 2/12/24 at 9:05 AM, during the initial tour of the facility kitchen revealed the following: - a plastic ice scoop was on top of the ice machine and was not in a holder; the top surface of the ice machine was soiled with dust and was gritty; - the shelf above the microwave oven was soiled with spilled spices; - a metal frame was attached to the wall, above the stainless steel shelf for clean dishes from dish machine and pans washed in the 3 compartment sink, and cooking utensils and frying pans were hanging from the frame with their sanitized food surfaces exposed to contaminants in the air; - the dry storage and non-perishable food storage room had a bulk container with brown sugar and had a plastic scoop inside the container in the sugar; a 5 pound bag of waffle mix was opened and placed in a resealable plastic bag but was not labelled and dated. Observation on 2/14/24 at 4:00 PM revealed the door to the walk-in refrigerator had been left open approximately 4 inches and the exterior unit thermometer read 42 degrees F. No dietary staff were in the walk-in refrigerator. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676365 If continuation sheet Page 10 of 11 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 676365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Park Rehabilitation and Care Center 300 Crowne Point Blvd Willow Park, TX 76087 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation and record review on 2/14/24 at 4:20 PM, [NAME] B was operating the low temperature dish machine to wash cooking utensils need for the evening meal food preparation. She stated she had not checked the water temperatures or sanitizer level for the dish machine. Review of the daily dishwasher machine log and water wash and rinse temperatures and chlorine sanitizer level revealed the water temperatures and sanitizer level had been documented for the evening meal and initialed by a dietary staff member. [NAME] B stated the initials were those of the morning cook. [NAME] B ran the dish machine and recorded the water temperatures and sanitizer level and initialed the form over what the morning cook had recorded. In an interview and record review on 2/15/24 at 5:20 PM, the Dietary Manager stated the staff used daily cleaning schedules. She provided the daily cleaning schedule form dated 2/05/24 - 2/11/24 for review. The shelves and stainless steel were initialed as being completed. The ice machine was not included on the cleaning schedule. Review of the facility policy for Food Safety - Food Service Manager's Responsibility, dated 2013, revealed the following [in part]: Policy: The food service manager is responsible for providing safe foods to all individuals. Procedure: The food service manager assures all of the following: 2. Sanitary conditions are maintained in the storage, preparation and serving areas. 3. Dishwashing guidelines and techniques are understood by staff and carried out in compliance with state and local health codes . 5. All refrigerated and frozen food are stored and handled properly. All dry and staple food items are stored properly . 7. All personnel follow proper cleaning and sanitizing instructions for all kitchen equipment. Cleaning schedules are posted and followed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676365 If continuation sheet Page 11 of 11