Willowbend Health And Rehabilitation, Llc

F-F689 at a lower severity.

The facility also failed to ensure aerosols, medications, perfumes, and creams were not easily accessible to

a resident to prevent accidental exposure for the 15 residents on the 100 Hall and 1 (Resident #93) of 8 sampled residents.

2. A review of the facility policy titled, Accident Hazards Prevention, stated, Resident Environment. The environment will be free from accident hazards as is possible; 3. Engages all staff, residents and families in training on safety, and promotes ongoing discussions about safety with input from staff at all levels of the organization.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 18 045412 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045412 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willowbend Health and Rehabilitation, LLC 830 Canal Street Marion, AR 72364

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 0689 a. On 02/04/2025 at 2:20 PM, during a concurrent observation and interview, Certified Nursing Assistant (CNA #12) was observed by Surveyor picking up a clear plastic bag and putting it back on the counter, Level of Harm - Immediate wheelchair height, at the 100 Hall nurses station leaving it easily accessible to residents. CNA #12 stated, jeopardy to resident health or [Resident #19] could come up here, grab this bag and take off down the hall with it. CNA #12 then took the safety trash and linen in barrels down the hall leaving the bag unattended. Resident #19 is observed wandering up and down the hallway. Surveyor observed that the clear plastic bag with a lighter and keys on the outside of Residents Affected - Few it hanging off of one of the black handles, inside the bag was a medication bottle, a lighter, creams, alcohol sprays, and perfumes were observed.

b. On 02/04/2025 at 2:27 PM, CNA #12 stated that the inside of the bag contained, [Name Brand] antibiotic ointment, alcohol spray, perfume, a lighter, Ibuprofen, and aerosol deodorant spray. CNA #12 stated that the bag was easily accessible to residents who wander up and down the hall, should have been stored out of reach and behind a door to keep residents out of it. CNA #12 continued stating that the items were hazardous to the residents, and they could drink something, or injure themselves with the contents in the bag. LPN #14 stated that hazardous materials should be kept out of reach of the residents.

c. On 02/06/2025 at 8:09 AM, during an interview the Director of Nursing (DON) stated that hazardous items such as perfumes, medications, and aerosol sprays should not be left out unattended and easily accessible by residents. The DON stated that a resident could get injured if items are left out unattended.

51477

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 18 045412 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045412 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willowbend Health and Rehabilitation, LLC 830 Canal Street Marion, AR 72364

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51477 Residents Affected - Some Based on observation, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure over-the-counter medications, and a narcotic medication prescribed to Resident #71, stored in the medication carts were not expired for 2 of 2 medication carts sampled.

The findings include:

Review of a facility policy titled, Medication Storage in the Facility, dated 1/1/2015, indicated All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner. Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are retained in the facility

in a securely locked area with restricted access until destroyed.

A review of Resident #71's Admission Record, initiated on 10/02/2020, indicated the facility admitted Resident #71 with Parkinson's disease without dyskinesia, without mentions of fluctuations (disorder of central nervous system that affects movement).

The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/07/2025, revealed Resident #71 had a Brief Interview for Mental Status (BIMS) score of 13, (13-15 indicates cognitively intact.)

Review of Resident #71's care plan, initiated 04/03/2023, revealed the resident was at risk for pain. Interventions included administer pain medications as ordered/needed. Notify MD [Medical Director]/Practitioner if not effective.

On 02/04/2025 at 3:10 PM, this surveyor observed Registered Nurse (RN) #21 during inspection of medication cart #1. This inspection revealed 6 medications that were expired. Medications found that were out of date were (Name Brand) Regular Strength Antacid/anti-gas medication; (Name Brand) Multipurpose Nail Repair, Docusate Calcium (stool softener) 240 milligrams, two calorie and protein dense nutritional drinks 2.0 Cal 237 milliliters, Extended Release Acetaminophen 650 milligrams, and Active Liquid Protein 887 milliliters.

On 02/04/2025 at 3:30 PM, this surveyor observed RN #17 during inspection of medication cart #2. This inspections revealed 7 medications that were expired. Medications found that were expired were Acetaminophen 500 milligrams, Extended Release Acetaminophen 650 milligrams, Aspirin 81 milligrams, Ibuprofen 200 milligrams, Milk of Magnesium 1200 milligrams, Aspirin 325 milligrams, and Morphine 20 milligrams/milliliter solution (this medication was prescribed to Resident #71).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 18 045412 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045412 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willowbend Health and Rehabilitation, LLC 830 Canal Street Marion, AR 72364

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 0761 During an interview with RN #11 on 02/05/2025 at 11:30 AM, she confirmed that when there was an order to discontinue or change an order for medications, those medications were taken to the medication room and Level of Harm - Minimal harm or stored in a container. She confirmed that narcotics were given to the Assistant Director of Nursing (ADON) potential for actual harm and the ADON recorded the medication in a logbook. She revealed that she notified the ADON and DON if there was a change in medication. Residents Affected - Some

During an interview with the ADON on 02/05/2025 at 11:37 AM, she confirmed that she handles the discontinued narcotics. She confirmed that any expired medications, discontinued medications, over the counter (OTC) medications from the medication carts were pulled from the carts, taken to the medication room, and the pharmacist destroyed them. The ADON confirmed the pharmacist did a match back from the medication destruction book and the medication card and then destroyed them. She confirmed if a narcotic had expired, or the resident had been discharged , the medication was removed, double signed in the narcotic book, and removed from the medication cart. She completed a form and put the resident's name on

the form along with the dosage, strength, prescriber, and how much medication was left for surrendering.

She revealed two people placed the medications along with the form in a box and send them back to the state for destruction.

During an interview with the DON on 02/05/2025 at 11:43 AM, she confirmed that over the counter medications, and prescribed medications were taken to the medication room and listed in the destruction book, placed in a locked trash can, then the pharmacist destroyed them. The DON confirmed she had a drawer that was double locked in her office for expired narcotic medications. She revealed the medication stayed locked in her office until the pharmacist came to the facility, or they have two people to verify the information and send it back to the pharmacy to be destroyed.

A review of the Acetaminophen capsules or tablets Safety Data Sheet, revised 8/14/2023 revealed, To get rid of medications that are no longer wanted or have expired: Take the medication to a medication take-back program. Ask your pharmacy or law enforcement to find a location. If you cannot return the medication, check the label or package insert to see if the medication should be thrown out in the garbage or flushed down the toilet. If you are not sure, ask your care team. If it is safe to put it ill the trash, empty the medication out of the container. Mix the medication with cat litter, dirt, coffee grounds, or other unwanted substances. Put it in the trash.

A review of the Acetaminophen Extended Release tablets Safety Data Sheet , revision on 8/14/2023, reveals To get rid of medications that are no longer needed or have expired: Take the medication to a medication take back program. Check with your pharmacy or law enforcement to find a location. If you cannot return the medication, check the label or package insert to see if the medication should be thrown out in the garbage or flushed down the toilet. If you are not sure, ask your care team If it is safe to put it in the trash, empty the medication out of the container. Mix the medication with cat litter, dirt, coffee ground or other unwanted substance. Seal the mixture in a bag or container. Put it in the trash.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 18 045412 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045412 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willowbend Health and Rehabilitation, LLC 830 Canal Street Marion, AR 72364

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 0761 A review of the Aluminum Hydroxide Magnesium Hydroxide Simethicone Safety Data Sheet, revision on 12/11/2024, reveals contain aspirin, ibuprofen, naproxen. Always read labels carefully. To get rid of Level of Harm - Minimal harm or medications that are no longer needed or have expired: Take the medication to a medication take-back potential for actual harm program. Check with your pharmacy or law enforcement to find a location. If you cannot return the mediation, check the label or package insert to see if the medication should be thrown out in the garbage or flushed Residents Affected - Some down the toilet. If you are not sure, ask your care team. If it is safe to put it in the trash, empty the medication out of the container. Mix the medication with cat litter, dirt, coffee grounds, or other unwanted substance. Seal the mixture in a bag or container. Put it in the trash.

A review of the Aspirin Tab lets Safety Data Sheet, revision date of 12/11/2024, revealed, To get rid of medications no longer needed or have expired: Take the medication to a medication take-back program. Check with your pharmacy or law enforcement to find a location. If you cannot return the medication, check

the label or package insert to see if the medication should be thrown out in the garbage or flushed down the toilet, If you [NAME] not sure, ask your care team If it is safe to put it in the trash, empty the medication out of

the container and mix the medication with cat litter, dirt coffee grounds, or other unwanted substance. Seal

the mixture in a bag or container. Put it in the trash.

A review of the Ibuprofen Capsules or Tablets Safety Data Sheet, revision on 12/12/2024, revealing, To get rid of medications that are no longer needed or have expired: take medication to a take back program.

A review of the Magnesium Hydroxide Solution Safety Data Sheet, revision on 5/9/2024, revealed Throw away any unused medication after the expiration date.

A review of the Morphine Solution Safety Data Sheet, revision on 12/4/2024, revealed, Misuse of this medicine can cause addiction or overdose. Take it exactly as prescribed. Store it in a safe place to prevent stealing or abuse. It is illegal to sell it or give it away. It is important to get rid of the medication as soon as you no longer need it or it is expired. To get rid of this medication: Take the medication to a take-back program. Check with your pharmacy or law enforcement to find location. Follow the steps given to you by your pharmacy. You may be given a pre-paid mail-back envelope or disposal product to safely get rid of your medication. If other options are not available, flush the medication down the toilet.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 18 045412 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045412 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willowbend Health and Rehabilitation, LLC 830 Canal Street Marion, AR 72364

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 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. Level of Harm - Minimal harm or potential for actual harm 03508

Residents Affected - Some Based on observation, record review and interview, the facility failed to ensure meals were prepared and served in accordance with the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed.

The findings are:

1. The week 1, Day-2 supper menu for Fall/Winter 2024 to 2025 specified for the residents on mechanical soft diets to receive 4 ounces of dressing and 4 ounces of turkey and all residents were to receive 1/2 cup of broccoli.

2. On 02/04/2025 at 3:49 PM, the following observations were made during supper meal preparation and service:

a. Dietary [NAME] (DC) #2 weighed turkey meat to be served to the residents for supper as follows. The first one weighed 4.5 ounces, second 5.9 ounces, third 3.7 ounces, fourth 3.6 ounces, fifth 3.2 ounces, and sixth 2.1 ounces. Total of 23 ounces. DC #2 placed a total of 23 ounces of turkey into the blender, ground and poured into a pan, then placed the pan in the oven to be served to 21 residents who received mechanical soft diets.

b. On 02/04/2025 at 5:58 PM, as DC #2 was ready to put more turkey meat into a blender to ground and serve to the 2 residents, DC #2 was asked to weigh turkey meat. After weighing it, DC #5 stated it was 5.1 ounces, which brought the total amount prepared to 28 ounces, instead of the intended 84 ounces.

c. On 02/05/2025 at 11:06 PM, DC #2 was interviewed, and asked how much mechanical soft turkey she had prepared for the supper meal on 02/04/2025. After I showed her the calculation, she confirmed that the amount she had prepared was correct but would not be enough for 21 residents.

2. On 02/04/2025 at 5:35 PM, during observation of the supper meal service, DC #3 used a #12 scoop (3 ounces) to serve a single portion of ground turkey to the residents on mechanical soft diets, instead of 4 ounces.

3. On 02/04/2025 at 5:56 PM, the kitchen ran out of stuffing and broccoli. After running out of stuffing and broccoli, DC #3 switched to a #12 scoop, (3 ounces or 1/3 cup) to serve a single serving of stuffing. This portion was 1 ounce less than what the menu specified. DC #3 served cut green beans to 4 residents, instead of broccoli. Resident #51 asked the Dietary Manager for broccoli. The Dietary Manager informed the resident that they had run out of it.

4. The week 1, Day-3 menu for Fall/Winter 2024 to 2025 breakfast specified for the residents on pureed diets were to receive a #8 scoop of pureed hash browns and a #16 scoop of pureed biscuits.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 18 045412 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045412 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willowbend Health and Rehabilitation, LLC 830 Canal Street Marion, AR 72364

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 On 02/05/2025 at 8:30 AM, during the breakfast meal service, there were no pureed hash browns or pureed biscuits served to the residents who required pureed diets for breakfast. At 9:10 AM, DC #2 was interviewed Level of Harm - Minimal harm or and was asked if there was a reason why residents on pureed diets were not served hash browns or biscuits potential for actual harm and she stated she forgot.

Residents Affected - Some 51477

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 18 045412 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045412 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willowbend Health and Rehabilitation, LLC 830 Canal Street Marion, AR 72364

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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 03508

Residents Affected - Some Based on observation, interview, and facility policy review, the facility failed to ensure food items in the refrigerator, freezer and storage room were covered, sealed and dated; 2 of 2 ice machines was maintained

in clean and sanitary condition; dietary staff washed their hands before handling food or clean equipment; kitchen storage area was maintained clean; and hot food items were maintained at temperature of 135 degrees or above for 2 of 2 meals observed.

The findings are:

1. On 02/03/2025 at 10:46, during the initial rounds with the Dietary Manager, the following observations were made:

a. A one-pound bag of marshmallows with no received date. The Dietary Manager confirmed the findings.

b. A cardboard box of pasta with two full ten-pound bags with no received date. The Dietary Manager confirmed the findings.

2. On 02/03/2025 at 11:03 AM, the following findings were observed in the walk-in freezer:

a. A cardboard box with 16.8 pounds of hash brown patties with no received date. The Dietary Manager confirmed the findings.

b. A cardboard box with five pounds of beef franks with no received date. The Dietary Manager confirmed

the findings.

c. Two cardboard boxes of chocolate ice cream, two cardboard boxes of strawberry ice cream, and one cardboard box of vanilla ice cream, all 1.5 gallons, with no received date.

3. On 02/03/2025 at 11:14 AM, the following findings were observed in the walk-in fridge:

a. A cardboard box with twenty-eight tomatoes with no received date or opened date. The Dietary Manager confirmed the findings.

b. A cardboard box with thirty pounds of scrambled eggs with no received date. The Dietary Manager confirmed the findings.

c. A cardboard box with nine half gallons of buttermilk with no received date or opened date. The Dietary Manager confirmed the findings.

d. A plastic bag of raw chicken wings was found on the third shelf next to other boxes of food with no date.

The Dietary Manager stated it is roughly two to three pounds.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 18 045412 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045412 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willowbend Health and Rehabilitation, LLC 830 Canal Street Marion, AR 72364

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 e. A cardboard box of bologna with no opened or received date, only one left out of two. The Dietary Manager stated that each one is five pounds and confirmed the findings. Level of Harm - Minimal harm or potential for actual harm f. A plastic container of cucumber and onion mix, about half full, had no opened or received date. The Dietary Manger confirmed the findings. Residents Affected - Some g. A plastic container wrapped in a supermarket bag, that was a staff member's lunch. The Dietary Manager confirmed the findings.

h. A plastic bag of shredded lettuce, that was browning with liquid at the bottom was left unsealed with no date. The Dietary Manager confirmed the findings.

i. A plastic container of ten pounds of coleslaw with no received date. The Dietary Manager confirmed the findings.

j. A plastic bag of raw chicken drumsticks found on the third shelf in the back corner, dripping liquid out of the right bottom corner. The Dietary Manager stated that raw chicken, such as those in the two bags found, were to be stored on the bottom to prevent cross contamination.

k. On 02/03/2025 at 11:25 AM, in the two-door cooler, a full pitcher of pink flavored drink mix was found with no date and no lid.

l. On 02/03/2025 at 11:27 AM, the Dietary Manager pulled out the grease drip pan. The first half was filled over halfway with grease and food drippings. The last half was filled with crumb coatings, that when pulled out the crumbs fell on to the floor of the kitchen. The Dietary Manager then pulled out the drip pan below the stove top. Lima beans covered the back half with burnt food debris and grease covering the rest. The back splash of the stove was covered in a thick layer of yellow grease. The Dietary Manager stated that all three of these are to be done daily and that they have not been cleaned as they should be.

4. On 02/03/2025 at 11:30 AM, this surveyor observed on the spice shelf a bag of grits, a fourth of the way full, had no opened or received date. The Dietary Manager confirmed the findings.

5. 02/04/2025 03:16 PM, the following observations were made in the kitchen area:

a. The edges of the steam table had food stains on it.

b. The shelf below the steam table where clean pans were kept had loose food crumbs on it.

c. The shelf below the food preparation counter, where pots and pans were kept, had loose food crumbs on it.

d. There were loose greasy food particles on top of the oven.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 18 045412 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045412 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willowbend Health and Rehabilitation, LLC 830 Canal Street Marion, AR 72364

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 6. On 02/04/2025 at 3:20 PM, Dietary [NAME] (DC) #2 was wearing gloves on her hands when she used a knife to cut open the wrap covering the turkey meat. After unwrapping the meat, DC #2 placed it on the Level of Harm - Minimal harm or cutting board and using her gloved hands, sliced the meat and placed it into a pan. DC #2 did not change her potential for actual harm gloves or wash her hands before continuing to slice the meat. DC #2 was interviewed and was asked what

she should have done after touching dirty objects and before handling food items. She confirmed she should Residents Affected - Some have changed gloves and washed her hands before proceeding.

7. On 02/04/2025 at 3:25 PM, DC #3 picked up a spoon from a measuring cup inside the dirty sink and used

it to scoop a serving of broccoli from a pan on the steam table. As DC #3 was about to transfer it into a blender, DC #3 was stopped and was asked if the spoon had been washed and sanitized. DC #3 confirmed that she should have washed and sanitized it before using it.

8. On 02/04/2025 at 3:28 PM, DC #3 placed gloves on her hands. DC #3 then moved the blender motor towards the edge of the counter, contaminating her gloves. Without changing her gloves and washing her hands, DC #3 picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets.

9. On 02/04/2025 at 3:43 PM, the panel below the ice machine in the kitchen where the ice forms before dropping into the ice collector had wet black residue hanging down from it. The corners inside the ice machine had black residue settled on them. The area was pointed out to the Dietary Manager, and he was asked if the residue buildup could be wiped off. He used tissue paper and wiped it off. The black, and slimy residue easily transferred to the tissue. The Dietary Manager was asked how often the kitchen staff cleaned

the ice machine and who used the ice from the machine. He stated the ice machine had been cleaned by the maintenance man once a month, and the kitchen staff used it to fill beverages served to the residents at the mealtimes. The Dietary Manager was interviewed and was asked to describe what he observed on the panel below the area where the ice forms before dropping into the ice collector. He stated there was black residue

on the panel and he will start cleaning it 2 times a week.

10. On 02/04/2025 at 4:45 PM, the temperatures of the food items on the steam table when checked and read by DC #3 were as follows:

a. Ground turkey - 125 degrees Fahrenheit.

b. Pureed bread - 91 degrees Fahrenheit.

11. On 02/04/2025 at 4:59 PM, the walk-in refrigerator was 39 degrees Fahrenheit. An opened box of turkey sausage was on a shelf in the walk-in refrigerator. The box was not covered or sealed.

12. On. 02/04/2025 4:05 PM, the following observations were made on a shelf in the freezer:

a. An opened box of burritos. The box was not covered or sealed.

b. An opened box of cookie dough. The box was not covered or sealed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 18 045412 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045412 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willowbend Health and Rehabilitation, LLC 830 Canal Street Marion, AR 72364

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 13. On 02/04/2025 at 5:48 PM, Dietary Aide (DA) #4 who was on the tray line assisting with the supper meal, picked up condiments and supplements with his bare hands and placed them on the trays, contaminating his Level of Harm - Minimal harm or hands. Without washing his hands, he picked glasses that contained beverages by their rims and placed potential for actual harm them on the meal trays to be served to the residents for the supper meal.

Residents Affected - Some 14. On 02/05/2025 at 7:38 AM, the left inside corner of the ice machine in the nourishment room on the 300 Hall had wet black residue on it. The area was pointed out to the Dietary Manager, and he was asked if the residue buildup could be wiped off. The Dietary Manager used tissue paper and wiped it off. The black residue easily transferred to the tissue. The Dietary Manager was interviewed and was asked to describe what he observed on the panel close to the area where the ice forms before dropping into the ice collector and who uses the ice from the ice machine. He stated there was black residue on it, that's the ice that the CNAs use for the pitchers in the residents' rooms. Maintenance was asked how often he cleaned the ice machine, and he stated CNA #12 cleans it. CNA #12 was asked how often she cleaned the ice machine. He stated once a month we treat the inside and wipe the panel every two weeks.

15. A review of facility policy titled, Handwashing and Glove Usage in Food service, initiated 2016, provided by the Dietary Manager on 02/05/2025 indicated that food handlers should wash their hands before starting work, after touching dirty dishes or clothing and after touching anything else such as dirty equipment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 18 045412