Willow Park Rehabilitation Health Care Center
Willow Park Rehabilitation Health Care Center in Clifton, TX — inspection on December 19, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
jeopardy to resident health or safety
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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