Willow Park Rehabilitation Health Care Center
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
LVN's, 2 RN's, and 8 housekeeping and dietary staff interviewed achieved 100% passing. Review of Resident #11's updated care plan dated 12/17/2025 reflected the following updates: Resident is two persons on one r/t resident behaviors and/or aggressions with peers. Intervene as necessary to protect the rights and safety of others. Approach/Speakin a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior andpotential causes. Staff to identify resident's triggers for behaviors and use de-escalation techniques. Staff to identify early warning signs for resident's behavior and triggers. Staff to identify resident's triggers for behaviors (loud noises, other peers in his personal space, people touching his clothing, he doesn't like to be changed when his clothing is soiled. Resident doesn't like crowded spaces.) Staff to identify early warning signs for residents' behaviors and triggers. (Resident starts fidgeting. Repeats words over and over and paces, starts pushing or pulling on staff.) In an observation/interview on 12/17/2025 at 9:04 AM, revealed 2 staff-CNA I and NA J stated they were assigned to work their 7am-7pm shift with Resident #11. They stated they were instructed by the DON that they were responsible for being within an arm's length away from Resident #11 and always keeping Resident #11 an arm's length away from his peers. They were to supervise him to ensure no altercations took place. They stated Resident #11 required 2 staff for care activities such as dressing, bathing, and changing. Resident #11 was observed sitting in a chair watching television in between CNA I and NA J. In interviews completed on 12/18/2025 between the time of 10:35 AM. and 12:00 PM with 9 CNA's, 2 MA's, 4 LVN's, 2 RN's, and 8 Housekeeping and Dietary staff, from various shifts, all staff were able to verbalize that they had been trained on managing residents with aggressive behaviors, Dementia related to aggressive behaviors, resident to resident abuse, prevention, and de-escalation. Staff were able to identify triggers that could possibly lead to incidents of aggressive behavior. Staff verbalized
they were educated on Resident #11 requiring 2:1 supervision on the secured unit. They were able to locate the resident's care plan along with the process revised from managing residents with aggressive behaviors. Staff were able to give examples of abuse and identified the administrator as the abuse coordinator. The CCS and RDO were informed the IJ was removed on 12/18/2025 at 2:30 PM. The facility remained out of compliance at a severity level of no actual harm and a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.
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Willow Park Rehabilitation Health Care Center in Clifton, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Clifton, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Willow Park Rehabilitation Health Care Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.