Health inspection·January 13, 2026

F 0880 Provide and implement an infection prevention and control program. 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 maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of three residents reviewed for infection control practices. MA A failed to perform hand hygiene while administering medication to Resident #1 MA A stuck her bare hands into a pill bottle of buspirone 15 mg which contained multiple pills. These failures could affect the residents by placing them at risk for the spread of infection.Finding included:Review of Resident #1's face Sheet dated 01/13/26, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of acute respiratory failure, Alzheimer's disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, behavior and is the most common cause of dementia), metabolic encephalopathy (a brain dysfunction caused by underlying metabolic disturbances, leading to symptoms like confusion, memory loss and altered consciousness), restlessness and agitation.Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed BIMS of 2 indicating Resident #1 had severe cognitive impairment. Resident #1 required substantial/maximal with most activities of daily living (ADLs).Review of Resident #1's care plan dated 04/04/23 revealed she used antianxiety medications related to anxiety disorder. The goal was for Resident #1 to be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date.Review of the MAR dated 01/01/2026 through 01/31/2016 for Resident #1 reflected the following:Cyanocobalamin oral tablet 250 mg-Give 1 tablet by mouth in the morning.Folic acid 1 mg-Give I tablet by mouth in the morningMemantine HCL 10 mg-Give 1 tablet by mouth two times a dayBuspirone HCL 15 mg-Give 1 tablet by mouth three times a dayDivalproex Sodium 125 mg-Give 2 capsules by mouth three times a dayLosartan Potassium 25 mg. Give 0.5 tablet by mouth in the morningMultivitamin with Minerals supplement. Give tablet by mouth in the morning.Observation of medication administration for Resident #1 on 01/13/26 at 9:10 a.m. revealed MA A did not wash her hands or perform hand hygiene before retrieving the medication from the medication cards. MA A stuck her bare hands into the bottle/container of buspirone 15 mg tablets touching multiple pills. MA A failed to wash her hands or perform hand hygiene after medication administration for Resident #1.In an interview on 01/13/26 at 9:26 a.m. with MA A, she said she had been employed in the facility since August 2025. She stated she received infection control training during her orientation. MA A stated cross contamination was not washing hands before providing care to a resident. She stated the resident could get sick if good infection practice was not followed.During an interview with the DON on 01/13/26 at 3:06 p.m. he acknowledged he was aware of some of the concerns raised about infection control practices She stated the aides were expected to follow standard protocols which include appropriate hand hygiene when administering medication. She stated the staff receive annual training on infection control and have initiated one-on-one training with MA A.Review of the facility's hand-washing policy from 2001 med-pass reflected:Policy Residents Affected - Few (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 676365 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 01/13/2026 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)