Health inspection·September 13, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the facility's provider investigation report for this incident, dated 08/23/23, stated in the investigation summary section: [Resident #3] was in the rehab gym in the standing [frame] and was complaining that his right arm was hurting him. The treating therapist, [PTA P], adjusted [Resident #3's] arm and provided him with some padding. [Resident #3] continued to complain of pain and began stating that he wanted to get out of the standing frame. [OT A] was sitting behind [Resident #3] at the desk. [OT A] slammed his hands down on the desk, turned and grabbed [Resident #3's] arm, forcing it down onto the bar and held his hand onto the standing frame. [Resident #3] stated that this hurt at which point [PTA P] intervened, removing [Resident #3] from [OT A]. [OT A] began aggressively moving equipment, yelling, and he then left the facility. The administrator and Director of Rehab phoned [OT A] and suspended him immediately, pending investigation. [Resident #3] was assessed by the treatment nurse, [LVN C]. [LVN C's] assessment revealed no physical injuries, no marks, no bruising, no redness of any kind and no emotional distress. Safe surveys were conducted on the residents that [OT A] treated. The safe surveys revealed no negative outcomes. The facility notified [Resident #3's] family and physician. The facility reported to [state survey agency] 8-16-23 at 1:19pm. Through interviews and investigation, the facility learned that therapists [PTA P], [PTA N], and [Therapy Tech O] witnessed the event. From their statements the facility gathered that [PTA P] was treating [Resident #3] and that [Resident #3] complained of pain in his right arm, was struggling with his stamina in the standing frame, and was impatient to be finished. After hearing [Resident #3] complain [PTA P] adjusted [Resident #3's], gave him some additional padding, and asked him to push through for just a little longer. [Resident #3] continued a bit longer and then began saying that held better be finished soon. [OT A] was sitting at the desk in the rehab gym. Upon hearing [Resident #3] complain again he became impatient, he got up and pushed [Resident #3's] right arm down onto the bar of the standing frame, he raised his [voice] stating that [Resident #3] was Interrupting other patients therapy and that [Resident #3] was [finished] with his therapy session. [PTA P] intervened and removed [Resident #3] from the rehab gym. [OT A] aggressively moved some equipment around and then left the facility. [Resident #3] was monitored throughout the investigation but he exhibited no initial, nor any delayed onset physical injuries nor any emotional distress. In a phone interview with the administrator [OT A] stated that he pushes people to complete their therapy but he would never physically or emotionally hurt someone. An in-service on abuse/neglect was begun with staff. The investigation reveals that the incident occurred: [OT A] became impatient with [Resident #3] in the rehab gym and responded by pressing his right arm down onto the bar of the standing frame, [stating] loudly that he wasn't going to let [Resident #3] interrupt other residents' therapy. This was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 2 of 17 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 676048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 1201 Fm 2685 Gladewater, TX 75647 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 0600 Level of Harm - Minimal harm or potential for actual harm witnessed by staff members [PTA P], [PTA N], and [Therapy Tech O]. Although the incident occurred, the facility could not substantiate abuse ([Resident #3] exhibited no initial nor any delayed onset physical injuries nor emotional distress and the safe surveys that were conducted with the patients being treated by [OT A] revealed no negative outcomes). [Resident #3] continues his stay at [facility] in [Resident #3's room number]. Residents Affected - Few Further record review of the facility's provider investigation report for this incident, dated 08/23/23, stated in the second investigation summary section: During the resident's therapy session, a therapist was witnessed speaking harshly to the resident and aggressively moving equipment near the resident. These actions could have caused the resident emotional trauma. The resident did not sustain any injury related to the incident and has not displayed any long-lasting emotional effects related to the incident. It is the belief of the facility that the therapist is solely responsible for the incident, and they did not behave appropriately while interacting with a resident of the facility. The therapist was immediately suspended at the time of the incident and has been terminated at the conclusion of this investigation. The incident was confirmed by three other employees near or within the vicinity during the interaction. During an interview on 09/12/23 at 2:36PM, LVN C said he took care of Resident #3 on 08/16/23. He assessed Resident #3 after the incident in the therapy gym and did not find any negative findings. He said there was no bruising or wounds. He said there was no physical or emotional injury to Resident #3. He said he did not act outside of his normal or show that it bothered him. He said Resident #3 did not require pain medication from the incident. He said he did not think OT A would hurt or be mean to a resident. He said he did not know OT A to be aggressive. During an interview on 09/13/23 at 7:53 AM, Resident #3 said he was doing his morning therapy on 08/16/23. He said OT A pushed his arm down on a machine in the therapy gym. He said when OT A pushed down his arm it was painful. He said it was at least a 7-8 out of 10 on a 1-10 pain scale. He said he did not require any pain medication after the event. He said it did not make him feel very good. He said it made him upset that someone would do that to him. He said before that event OT A had never been aggressive or forceful with him before. He said no one else in the facility was trying to hurt him. He said if there was abuse he would talk to the nurse and administrator. During an interview on 09/13/23 at 9:18 AM, PTA N said he was working on 8/16/23 when the incident occurred with OT A and Resident #3. He said Resident #3 was in the standing frame machine for therapy and he saw OT A walk over to Resident #3 and he saw Resident 3's arm jerk downward as OT A was aggressively trying to remove Resident #3 from the machine. He said he heard some loud talking and he saw two therapists intervene and stop OT A. He said OT A got irritated easily but he had never seen him be physical with a resident before. During an interview on 09/13/23 at 9:18AM, Therapy Tech O said Resident #3 was in the standing frame in the therapy gym. She said PTA P was the treating therapist for Resident #3 and OT A was assisting. She said she heard Resident #3 complain about being in the standing frame and say he wanted to be finished with the frame. She said OT A then told Resident #3 you need to calm down and Resident #3 said don't talk to me like that. OT A told Resident #3 we're not doing this today. She said OT A aggressively took Resident #3 off of the standing frame and she saw OT A jerk down Resident #3's arm. She said Resident #3 was loudly arguing with OT A but he did not scream out in pain. She said she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 3 of 17 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 676048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 1201 Fm 2685 Gladewater, TX 75647 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few then left the room right as PTA P intervened. She said OT A had always been easily irritated when residents would complain in the therapy gym. She said she had never seen OT A be physically aggressive before. During an interview on 09/13/23 at 9:35AM, PTA P said she was treating Resident #3 on 08/16/23. She said they were working on standing endurance with Resident #3. She had a goal of 15 minutes in the standing frame for Resident #3. He had a few minutes left and wanted to be finished. She added a pad to the frame because he complained of pain to his arm. She encouraged Resident #3 to push through to meet his goal. She walked away to assist to another resident and OT A was sitting in a desk behind Resident #3. She said OT A had always been impatient and easily frustrated. She said after Resident #3 complained again about wanting to be finished with his therapy, OT A got upset with Resident #3 and slammed his hands down on the desk. She said OT A stood up and stormed towards Resident #3 and grabbed his right arm and push it down aggressively. She said Resident #3 yelled at OT A and told him to have some compassion when he jerked his arm. She said she immediately intervened, and OT A was being aggressive and rough with Resident #3. She told OT A she was going to take Resident #3 to his room and then OT A stopped being aggressive. She said OT A then apologized to her. She said sometime after this incident, he left the facility. She said she reported it to the facility DON, ADM, and director of rehab. She said OT A had been verbally aggressive before. She thought OT A crossed a line by putting his hands on a resident in that manner. She said OT A had anger issues and a short temper. She said as far as she knew he has never been physical with a resident. During an interview on 09/13/23 at 10:02AM, OT A said Resident #3 was standing in the standing frame. He said he was trying to help Resident #3 out of the frame. He said Resident #3 was raising his voice and he matched his loud tone. He said he tried to help lower Resident #3 to his wheelchair. He said he thought Resident #3 was balling up his fist to hit him, so he grabbed Resident #3's hand and held it down. He said he was trying to avoid jerking Resident #3's arm so he grabbed it to support it, and he saw Resident #3 make a fist so he moved his arm closer to his body so he could not hit him. He sat back down to the wheelchair and another therapist took him to his room. He said he cannot recall if anything else happened. He said he went to check on him after this and wanted to speak with the resident to make sure he was okay. He said he had worked with the resident a few times before this incident. He didn't think Resident #3 was appropriate for therapy because he got emotional, and he thought Resident #3 was not appropriately medically managed. He said he had worked at the facility before the incident about 18 months. He said he had received training on abuse and neglect. He said it was unfortunate what happened, and he was ultimately fired for unprofessional conduct. He said he had learned from this incident and wants to be a better clinician and has respect for the facility's decision to terminate his employment. During an interview on 09/13/23 at 3:59 PM, the DON said a therapist came to her office and asked to speak with her. She said it was reported to her that OT A had been involved in an incident with Resident #3. She said OT A had left the building for lunch. She said when OT A came back from lunch, they told him he was not allowed in the building and was suspended pending investigation. She said she interviewed the therapists in the gym that day. She said they told her OT A was aggressively speaking at Resident #3. She said one therapist told her OT A was holding down Resident #3's arm with force. She said OT A was ultimately terminated. She said she expected the therapists to treat the residents well, and not be aggressive with them. She said the risk to Resident #3 was that he could have been physically injured and had possible emotional trauma. She said Resident #3 could have feared the therapists and not want to go to therapy. She said she felt like OT A's verbal aggression was abuse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 4 of 17 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 676048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 1201 Fm 2685 Gladewater, TX 75647 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 09/13/23 at 4:21 PM, the Director of Rehab said he was called by a PTA and there was an incident between OT A and Resident #3. He said he was worried about abuse. He said he notified the Administrator. He said OT A was suspended pending investigation. He said he was told OT A yelled at Resident #3 and pulled his arm down to the table on the standing frame. He said ultimately they terminated OT A. He said he thought Resident #3 was emotionally and verbally abused based on the investigation. He said Resident #3 did not have any sign of injury after the incident. He said the risk to Resident #3 could be insecurity and fear of therapy. During an interview on 09/13/23 at 4:27 PM, the Administrator said he began working at the facility on 08/07/23. He said the allegation was that Resident #3 was in the therapy gym, being treated by PTA P. He said Resident #3 started to complain about pain in his right arm. PTA P adjusted his right arm and encouraged him to hold out. Resident #3 complained again that he wanted to be done soon. OT A was annoyed and slammed his hands down on the desk. He said OT A pushed down Resident #3's right arm. He said OT A told Resident #3 I'm not going to let you interrupt other residents' therapy time. PTA P intervened and separated OT A and Resident #3 and OT A left the building. After this the Administrator and the DON phoned OT A and suspended him immediately pending investigation. He said he did not refer OT A's license. He said ultimately the facility terminated OT A. He said the risk to Resident #3 was that the resident could suffer physical or emotional injury. He said he did not think that the incident was abuse. Record review of the facility's policy on abuse prevention and reporting, last revised December 2020, stated: .It is the policy of this facility that: 1. Residents will be free from verbal abuse, physical abuse, mental abuse, sexual abuse, involuntary seclusion, neglect, and exploitation. 2. Residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff [of] other agencies serving the residents, family members or legal guardians, friends, or other individuals. 3. All allegations of abuse are investigated Record review of the facility's policy on abuse: prevention of and prohibition against, last revised 11/28/17, stated: .It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility will provide oversight and monitoring to ensure that its staff, who are agents of the facility, deliver care in services in a way that promotes and respects the rights of the residents to be [free] from abuse, neglect, misappropriation of resident property, and exploitation. For purposes of this policy, staff includes: employees, the medical director, consultants, contractors, volunteers. Staff would also include caregivers who provide care and services to residents on behalf of the facility . .D. Prevention . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 5 of 17 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 676048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 1201 Fm 2685 Gladewater, TX 75647 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 0600 .2. The facility will take action to protect and prevent abuse and neglect from occurring within the facility by: Level of Harm - Minimal harm or potential for actual harm *Supervising staff to identify and correct and inappropriate or unprofessional behaviors . Residents Affected - Few .*Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur, to include validation that the facility has deployed the correct number of competent staff on each shift to meet the needs of the residents . .I. Definitions . .*Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . .*Mental abuse included, but is not limited to humiliation, harassment, and threats of punishment or deprivation . .*Verbal abuse included the use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their representatives, or within their hearing distance, regardless of their age, ability to comprehend, or disability Record review of the facility's policy on resident rights, revised May 2007, stated: .It is the policy of this facility that all resident rights be followed per state and federal guidelines as well as other regulative agencies. The resident has the right: 1. To be treated with consideration, respect and full recognition of his or her dignity and individuality. 2. To be free from verbal, sexual, mental or physical abuse, corporal punishment, involuntary seclusion and any physical or chemical restraint imposed for purposes of discipline or convenience or for other than treating medical symptoms FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 6 of 17 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 676048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 1201 Fm 2685 Gladewater, TX 75647 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and each resident received adequate supervision to prevent accidents for two of two residents (Resident #1 and #2) reviewed for accidents and hazards in that: 1. The facility failed to update Resident #1's elopement evaluation after he exhibited exit seeking behavior, and Resident #1 was able to elope from the facility without staff's knowledge due to an exit door failing to activate and Resident #1 was found on the roadway by police 2. The facility failed to ensure coffee was served at a safe temperature for Resident #2. Resident #2 received second degree burns to the left arm and abdomen after hot coffee was spilled on her. Resident #2 was not thoroughly assessed for burns after the coffee was spilled and treatment was not provided to the abdominal burn until 2 days after the incident occurred 3. The facility failed to have a policy to ensure coffee temperatures were at the appropriate temperature prior to serving These failures resulted in the identification of an Immediate Jeopardy (IJ) on 09/12/23 at 02:06 PM. While the IJ was removed on 09/13/23 at 1:45PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place the residents at risk for further elopement, burns, serious harm, serious injury, or death. Findings included: 1. Record review of Resident #1's face sheet, dated 09/11/23, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included generalized muscle weakness (decreased strength and compromised ability to perform active movements), type 2 diabetes mellitus (a long-term medical condition in which your body doesn't use insulin properly, resulting in unusual blood sugar levels), and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Record review of Resident #1's admission MDS assessment, dated 02/20/23, indicated he did not have a BIMS conducted because he was rarely/never understood. He had problems with both short-term and long-term memory, and his cognitive skills for daily decision making were severely impaired. He required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. He required supervision assistance with eating. Resident #1's locomotion on and off unit were not coded in the assessment because he had only performed those activities once or twice during the assessment. He used a wheelchair as a mobility device. Resident #1 received antidepressant medications 7 of 7 days of the assessment. Record review of Resident #1's care plan, created and initiated on 03/27/23, indicated a focus of elopement risk/wanderer related to disoriented to place, history of attempts to leave facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 7 of 17 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 676048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 1201 Fm 2685 Gladewater, TX 75647 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 unattended, impaired safety awareness, resident wanders aimlessly. Interventions included: Level of Harm - Immediate jeopardy to resident health or safety *Assess for fall risk *Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book Residents Affected - Few *Document wandering behavior and attempted diversional interventions *Establish behavior patterns in the resident: look for patterns in the places the resident wanders repeatedly, what time of day they tend to wander most, and if the resident was engaging in a particular activity prior to wandering. *Monitor fatigue and weight loss *Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes *Redirect them once you have distracted them: once you have gained their attention, redirect them in an assuring manner Further record review of Resident #1's care plan, created and initiated on 02/20/23, indicated a focus of at risk for falls related to decreased mobility and poor safety awareness. Interventions included: *Avoid rearranging furniture *Be sure the call light is within reach and encourage to use it to call for assistance as needed *Bed in lowest position *Educate resident/family/caregivers about safety reminders and what to do if a fall occurs *Ensure resident is wearing appropriate footwear when ambulating or wheeling in wheelchair *Needs a safe environment: floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; side rails as ordered, handrails on walls, personal items within reach Record review of Resident #1's progress note, dated 03/21/23 at 09:49AM, stated: resident going into other rooms, per resident that is [alert and oriented] went into her room last night, attempted to go into kitchen this am but staff present and redirected, shower given this am. Record review of Resident #1's progress note, dated 03/21/23 at 01:03 PM, written by RN H, stated: Resident propelled self using wheel chair to hall one exit door. Resident pushed the door attempting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 8 of 17 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 676048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 1201 Fm 2685 Gladewater, TX 75647 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 to exit setting off the alarm. This nurse turned off the alarm and redirected the resident back to the nurses station. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #1's progress note, dated 03/23/23 at 02:21 PM, stated: Residents Affected - Few noted resident going into others room, per other staff members taking belonging from other rooms, belongings returned Record review of Resident #1's progress note, dated 03/24/23 at 05:45 PM, written by LVN G, stated: [Resident] attempted to go out back door on hall 400. Staff quickly redirected [Resident]. Alarm reset. [Resident] wanders, propels self in wheelchair. Record review of Resident #1's progress note, dated 03/25/23 at 03:47PM, written by LVN G, stated: [Resident] has attempted to go out door on hall 100 & hall 300 today. Sat at front door attempting to open door unsuccessfully. Record review of Resident #1's progress note, dated 03/27/23 at 09:46AM, stated: Up in [wheelchair] and propels self .continues to attempt to go into others room Record review of Resident #1's progress note, dated 03/28/23 at 05:02 AM, stated: Received call from [facility's city police department] that a [name of facility] patient was on [local farm-to-market road] in a [wheelchair]/ This nurse and 2 CNAs went out to road to find patient in [wheelchair] on the side of the road by the driveway turn in. Spoke with police, thanked him and brought patient via [wheelchair] back into building. No alarms went off. No employees let him out. Patient placed in bed. 15 min check in place. DON notified. Will continue to monitor. Record review of Resident #1's elopement / wandering evaluation, signed on 02/13/23, indicated Resident #1 was a low risk. Record review of Resident #1's elopement / wandering evaluation, signed on 03/28/23, indicated he was a high risk. Record review of Resident #1's incident report, dated 03/28/23, indicated the city police had called the facility and informed them that a patient was on the road in front of the facility in a wheelchair. A nurse and two CNAs went out and brought the resident back into the facility. There were no injuries observed. He had a predisposing situation factor of being an active exit seeker and a wanderer. Record review of the facility's provider investigation report for Resident #1's elopement stated in the second investigation summary section: .Evaluation of facility doors revealed the door alarm closest to the resident's room was not activated at the time of his elopement . During an interview and observation on 09/11/23 at 1:58 PM, the Maintenance Director said he was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 9 of 17 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 676048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 1201 Fm 2685 Gladewater, TX 75647 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few working in the facility when the resident eloped in March 2023. He said the resident got out because the doors did not lock at the time of the incident. He said he was unsure if the alarm went off or not at the time of the incident. He tested all of the door alarms weekly, sometime during the week. He said he did not check on a specific day. He said he kept the checks on a log. He said the front and the back door were secured and alarmed. He said before the elopement, only the front and back door were secured. He said the other doors were only alarmed but not locked. They could still be pushed opened to allow egress. He said the nurses and the Maintenance Director had a key to the alarm. He said after the elopement all exterior doors were upgraded so they could be secured in the same way as the front and back door with a magnet lock. They were all alarmed. He took this surveyor around the facility and checked each exterior door and they were all secured and alarmed. During an interview on 09/11/23 at 2:58 PM, CNA M said she remembered seeing Resident #1 around 3:00 AM. She said she missed out on everything because the others ran outside. She said the nurses had a key to the alarms. She said she had never seen anyone turn off the alarm. She said she thought they were always on. She said she never heard an alarm sound that morning when the resident eloped. During an interview on 09/11/23 at 3:04 PM, CNA L said Resident #1 had behaviors before of exit seeking and trying to exit. She was not sure how he got out of the facility at the time of the elopement. She said he got out and they noticed he was missing and ran out to look for him and they found him at the end of the parking lot next to the road. She said he did not exhibit any distress. They got him back inside and the nurse looked him over. She said she was not sure if she heard an alarm that morning. She said the nurses had a key to the alarms. During an interview on 09/11/23 at 3:14 PM, CNA K said she dressed Resident #1 that morning. She said she brought him to the front of the building near the nurses station and gave him some snacks to keep him occupied. She said he then wandered around the facility either to the dining room or another hall. When she came back to check on him, he was not in the same spot when she left him. She said she could not find him in his usual places. The PD called and he was out of the facility down beside the street. They found him out of the parking lot by the side of the street. She said he did not have any injuries. She said they brought him back into the facility. She said later that day after her shift the DON or the ADON called her and they said the 400 hall door was found unlocked. She said she never heard an alarm that morning. She said she last saw him around 5-10 minutes before they found him outside. She said the nurses and the ADON have a key to the alarms. She said he just mumbled when asked how he got out. During an interview on 09/11/23 at 3:25 PM, LVN B said she said took care of Resident #1 the next shift after his elopement. She said he did not have any negative effects and did not have any injuries related to the elopement. During an interview on 09/11/23 at 3:29 PM, the ADON said Resident #1 got out of the building. She said the nurse assessed him. She said Resident #1 had no negative effects. She said he was outside around 10-20 minutes. She said they put him on 1:1 observation until he left to another facility later that day on 03/28/23. During an interview on 09/11/23 at 3:32 PM, the DON said she headed the facility's investigation. She said one of the nurses found that the alarm was turned off after Resident #1's elopement. She said when she arrived to the facility on [DATE], she checked the doors and the alarms were activated. She said one of the nurses that were working at the time of the elopement told her that the alarm to the 400 hall was turned off. She said the 400 hall door was the only one that was found not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 10 of 17 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 676048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 1201 Fm 2685 Gladewater, TX 75647 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few activated. She said the nurses had a key at the time of the elopement. She said after the incident, they changed the door locks to magnets that auto lock. She said Resident #1 was put on 15-minute checks until he was transferred out to another facility. She said they reevaluated all elopement risk residents. She said they did in-services related to the alarms. She said her investigation found that the resident was out of the building about 20-25 minutes. She said the current administrator had only been there about 1 month. During an interview on 09/11/23 at 4:00 PM, the DON said they did not have a policy that addressed how often the door alarms should be checked. During an observation on 09/11/23 at 4:16 PM, this surveyor found a speed limit sign for the road that the facility driveways end on. The speed limit was 55 miles per hour. During an interview on 09/11/23 at 4:43 PM, RN H said he did not remember taking care of Resident #1. He said he wrote a progress note on 03/21/23 likely because he noticed the resident was exit seeking. He said he could not recall the event but he said he would have notified the nurse and the DON about the new exit seeking behaviors. He said he was unsure if a new elopement assessment was completed on Resident #1 related to his exit seeking. During an interview on 09/11/23 at 4:49 PM, LVN G said Resident #1 was frequently exit seeking. She said she kept a closer eye on him since he started exit seeking. She said the hall doors had alarms and would sound when someone opened the door. She said she was unable to remember if a new elopement assessment was completed or if the DON was notified about Resident #1's exit seeking behaviors. She said for a resident that was a low risk to elope and then started to be exit seeking, she said she would notify the DON and complete a new elopement risk assessment. She said she did not create a new elopement/wandering risk assessment for Resident #1 when she noticed his exit seeking behaviors. During an interview on 09/12/23 at 9:09 AM, the DON said she last conducted an elopement in-service in March 2023 after Resident #1 eloped. She said newly hired employees were taught about elopement during their orientation training. She said she expected to be notified about Resident #1's new exit-seeking behaviors prior to his elopement. She said she expected the nurses to complete a new elopement assessment when they noticed new exit-seeking behaviors. During an interview on 09/12/23 at 9:14 AM, the Administrator said he did an in-service on elopement with the nurses on 09/11/23 after this surveyor left the facility. 2. Record review of Resident #2's face sheet, dated 09/12/23, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included generalized muscle weakness (decreased strength and compromised ability to perform active movements), and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Record review of Resident #2's quarterly MDS assessment, dated 07/03/23, indicated she did not have a brief interview for mental status conducted because she was rarely/never understood. Her staff assessment for mental status indicated she had a problem with both short and long-term memory, and that her cognitive skills for daily decision making were severely impaired. She did not exhibit behaviors of rejection of care or wandering. She required extensive assistance with bed mobility, transfers, locomotion on and off unit, dressing, eating, toileting, and personal hygiene. Her primary medical condition that best described her primary reason for admission was non-traumatic brain dysfunction (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 11 of 17 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 676048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 1201 Fm 2685 Gladewater, TX 75647 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 brain injury not caused by external physical force or trauma exerted on the head). Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #2's physician's orders, dated 09/12/23, indicated he had these orders: Residents Affected - Few *Cleanse left arm wound with normal saline/wound cleanser, apple silver sulfadiazine cream (used with other treatments to help prevent and treat wound infections in patients with serious burns) to left arm BID and cover with kerlix (a brand of gauze that is used to cover wounds) every shift for wound healing. The start date was 07/07/23. *Cleanse lower left abdomen wound with normal saline/wound cleanser, apply silver sulfadiazine cream to left arm BID and cover with kerlix every shift for wound. The start date was 07/09/23. Record review of Resident #2's care plan, created on 07/10/23, indicated a focus of Resident #1 has actual impairment to skin integrity related to burn to left arm from spilt coffee. The focus also indicated 07/09/23 burn areas noted on abdomen - resident refusing treatment frequently due to impaired cognition. Interventions included: *Notified wound MD, orders implemented *Educate resident/family/caregivers of causative factors and measures to prevent skin injury. *Follow facility protocols for treatment of injury *Identify/document potential causative factors and eliminate/resolve where possible *Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs or symptoms of infection, maceration to MD. Further record review of Resident #2's care plan, created on 07/25/2019, indicated a focus of Resident #2 is at risk for impaired cognitive function/dementia or impaired thought processes. Interventions included: *Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any distractions. Use simple, directive sentences. Provide with necessary cues - stop and return if agitated. *Engage in simple, structured activities that avoid overly demanding tasks Further record review of Resident #2's care plan, created on 07/10/23, indicated a focus of Resident #2 is resistive to care as evidenced by refusing wound care treatments related to dementia. Interventions included: *Encourage as much participation/interaction by the resident as possible during care activities *If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again *Praise when behavior is appropriate Record review of Resident #2's incident report, dated 07/07/23, indicated she was given a cup of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 12 of 17 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 676048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 1201 Fm 2685 Gladewater, TX 75647 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 Level of Harm - Immediate jeopardy to resident health or safety coffee on 07/07/23 in the morning in the dining room. She spilled coffee on her left arm and abdomen causing a burn. The incident indicated Resident #2's arm was assessed, cleaned, and silver sulfadiazine cream was applied. A note at the bottom of the incident report indicated Resident #2 spilled coffee on her arm during breakfast causing a burn, and education was provided to the kitchen regarding coffee temperatures. Residents Affected - Few Record review of Resident #2's progress note, dated 07/07/23 at 01:32 PM, written by LVN B, stated: resident was given a cup of coffee this morning in the dining room, resident spilled the coffee on her left arm causing a burn. Treatment nurse, [LVN C], notified and treatment of SSD cream implemented . Record review of Resident #2's progress note, dated 07/09/23 at 05:26 PM, written by LVN B, stated: during rounds this shift it was observed that resident has two burns to left side of abdomen. Area was cleaned with NS and SSD cream applied and covered with dry dressing. Wound care nurse notified and orders put in . Record review of Resident #2's progress note, dated 07/11/23 at 07:18 PM, written by LVN C, stated: Resident evaluated this AM by [Wound care doctor E]. Following wound evaluated: -[left] arm and [left upper quadrant abdomen]: burn to area, 11x10x0.1 cm, 110.00 cm^2, light serous drainage, 80% granulation tissue/20% skin. [treatment] of silver sulfadiazine and rolled gauze daily . Record review of Resident #2's skin evaluation, dated 07/07/23 at 09:05 AM, indicated Resident #2 had a burn to her left upper arm, forearm, antecubital area (the region of the arm in front of the elbow), and forearm. Record review of Resident #2's initial wound evaluation and management summary, dated 07/11/23, indicated she had a burn wound to her left arm that was a full thickness burn (third-degree burn). The wound size was 11 x 10 x 0.1 cm, and the surface area was 110.00 cm^2. The summary further stated: During today's visit, 35 minutes were spent in providing patient care related to reviewing of history, relevant investigations, performing examination, and/or coordination of care and counseling specific to Burn wound of the Left Arm . The summary did not address the burn of Resident #2's abdomen. The exam portion of the summary indicated Resident #2's abdomen was normal, and that there was a wound present to Resident #2's left upper extremity. Record review of Resident #2's wound evaluation and management summary, dated 07/18/23, indicated she had a burn wound to her left arm. The wound size was 10 x 5 x 0.1cm, and the surface area was 50.00 cm^2. The exam portion of the summary indicated Resident #2's abdomen was normal, and that there was a wound present to Resident #2's left upper extremity. The summary did not address the burn of Resident #2's abdomen. Record review of Resident #2's wound care progress note, with a date of service of 07/18/23, and signed by Wound Care Doctor E on 07/20/23 at 3:17PM stated: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 13 of 17 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 676048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 1201 Fm 2685 Gladewater, TX 75647 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The patient has partial second degree burns on the abdomen as well. However, the wounds are not open. We will apply Silvadene to wounds with dry dressing daily and prn. Record review of Resident #2's skin ulcer non-pressure assessment, dated 07/11/23 and completed by LVN C, indicated Resident #2 had a burn to her left arm and left lateral (of or relating to the side) abdomen. The onset date was 07/07/23. The size was 11x10 cm. The burn was described as a full thickness wound. The wound was noted to have a small amount of serous exudate (a clear fluid that leaks out of wounds). Record Review of Resident #2's wound care progress note, dated 7/11/23, and signed by Wound Care Doctor E on 09/13/23 at 10:05 AM, indicated that the wound care note dated for 07/18/23 concerning Resident #2's abdominal wound progress note was supposed to be dated for the 7/11/23 visit. This record was provided by the Administrator via email to this surveyor on 09/13/23 at 12:49 PM. Wound Care Doctor E signed this note on 09/13/23 at 10:05 AM, after surveyor interview with the Wound Care Doctor E, and after this surveyor notified the Administrator and DON of IJ on 09/12/23. During an interview on 09/12/23 at 9:40 AM, LVN B said she looked at the burn on Resident #2's left arm and grabbed the wound care nurse, LVN C. She said they immediately rinsed it with water and the wound nurse treated and bandaged the burn. She said she spoke with the kitchen about not giving out hot coffee. She said the resident had not had coffee before and she was unsure if it was given because she asked or if the kitchen had mistakenly given it to her. She said she notified the MD, DON, and family. During an interview on 09/12/23 at 9:55AM, LVN B said she did not notice the burn to Resident #2's abdomen on 07/07/23. During an interview on 09/12/23 at 10:05AM, LVN C said Resident #2 had sustained a coffee burn. He said he did not notice the burn to her abdomen on 07/07/23. He said the abdominal burn was found sometime between 07/07/23 and 07/11/23 because he remembered telling Wound Care Doctor E to look at both wounds on 07/11/23. During an interview on 09/12/23 at 10:19AM, LVN B said she found Resident #2's abdominal burn on 7/9/23. She said she was not told in report about the burns and treated them as new. She thought they were delayed from the coffee burn on her arm on 7/7/23. She said she immediately cleaned and treated the wound, and notified the DON, MD, Family, and treatment nurse. During an interview on 09/12/23 at 10:30AM, the Dietary Manager said they did not log the coffee temperature before the burn incident on the morning of 07/07/23. She said before the incident she expected the aides to read the temperature reading on the coffee maker and not to serve if the coffee temperature was greater than 180 degrees F. She said the dietician gave her some guidance at the time of the event that indicated there was no minimum or maximum that the coffee should be served. She said in the mornings the dietary aides assisted the nursing staff to give out coffee before breakfast. She after the burn incident they changed to use a thermometer to check the temps of the coffee and keep a log. She said the residents also now have coffee cups with lids to reduce the risk of spillage. She said the coffee maker was set to 200 degrees F and the coffee was usually around 180 degrees F when it finished brewing. During an interview on 09/12/23 at 10:40AM, the DON said they do not have a policy that addresses the coffee temperature or the temperature that would be safe to serve to residents. She said after (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 14 of 17 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 676048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 1201 Fm 2685 Gladewater, TX 75647 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 the incident the dietician provided some guidance that they now follow. Level of Harm - Immediate jeopardy to resident health or safety During an interview on 09/12/23 at 10:51AM, LVN D said she was called into the shower room and noticed the burn on Resident #2's L Arm. She did not observe an abdomen burn on 07/07/23. She treated and covered the wound as ordered by the wound care doctor. She notified the MD, nurse, and DON. She was not sure if Resident #2 normally drank coffee. Residents Affected - Few During an interview on 09/12/23 at 11:28AM, LVN B said he was unsure if Wound Care Doctor E saw the burn to Resident #2's abdomen on the 11th. He said he was not sure if Wound Care Doctor E was going to look at the abdominal wound or not. He said sometimes Wound Care Doctor E does not look at wounds the facility can treat. During an interview on 09/12/23 at 11:35AM, the DON said she expected Wound Care Doctor E to assess and treat the abdominal wound on 7/11/23. During an interview on 09/12/23 at 11:37AM, Wound Care Doctor E said Resident #2 had a big burn wound on her left arm and it never appeared to be infected. He said he was unsure if he saw the abdominal part of the wound on 7/11/23. He said he knew he saw it on the 7/18/23 visit. During an interview on 09/12/23 at 12:50PM, the DON said her investigation showed that Resident #2 spilled coffee on herself during breakfast. The CNA first noticed the burn to Resident #2's left arm when undressing her for a shower after breakfast. She said the CNA noticed the burn approximately at 9 to 9:30 AM. She said the resident did not express pain or any facial grimace. During an interview on 09/12/23 at 12:56PM, the Dietary Manager said they started the coffee temperature log the day after the burn incident. She said it was possible she put the coffee temps for the 8th on the 7th line. She said she did not have a record of the coffee temperature for the morning of the 7th. She said coffee was normally served between 6:30-7AM and breakfast was normally served at 7:15AM. During an interview on 09/12/23 at 3:46PM, CNA F said she took care of Resident #2 on 07/07/23. She said the resident had breakfast in the dining room and then participated in an activity. She said after the activity she took her out of the dining room to bathe her at approximately 10:00 AM. She said she noticed Resident #2's jacket was wet and undressed her. She then noticed a reddened area to Resident #2's left arm. She said she did not remember if Resident #2 had any reddened areas on her abdomen. She said she notified the nurse about the reddened area. During an interview on 09/13/23 at 3:50PM, the ADON said she expected the 400-hall alarm to be turned on at all times. The risk to Resident #1 was that he could have gotten hurt or injured. She expected the nurses to follow the elopement policy. During an interview on 09/13/23 at 3:59 PM, the DON said the risk to her Resident #2 as a result of the abdominal burn not being identified for two days was that she could have had skin breakdown or an infection. She said she expected the nurses to complete a new elopement evaluation when they noticed Resident #1 had new exit-seeking behaviors. She said she expected the 400-hall alarm to be turned on at all times. She said the risk to Resident #1 eloping could have been serious injury. Record review of the facility's policy titled elopement / unsafe wandering, last revised on January 2022, stated: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 15 of 17 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 676048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 1201 Fm 2685 Gladewater, TX 75647 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 .It is the policy of this facility to provide a safe environment for all residents through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement . Level of Harm - Immediate jeopardy to resident health or safety .Procedure Residents Affected - Few 1. Resident with capabilities of ambulation and/or mobility in wheelchair will have an elopement/wandering evaluation completed to determine risks for elopement and unsafe wandering on admission and with observed behaviors of wandering or attempting to elope. 2. Residents with high risk factors will be identified as at risk and will have an individualized care plan developed that included measurable objectives and timeframes. a. Care plan interventions will consider the elements of the evaluation or behavior observations that identified the resident at risk. b. interventions will address the individualized level of supervision needed to prevent elopement/unsafe wandering. 3. Staff shall promptly report any resident who is trying to leave the premises or is suspected of being missing to the Charge Nurse or Supervisor to evaluate the need for further interventions Record review of an undated coffee safety Inservice sheet, provided by the DM on 09/12/23 at 10:39AM stated: .*Coffee should be brewed around 180 degrees F per the manufacturer's recommendation for flavor. *There is no temperature minimum or maximum for point of service. *Temperature designation at point of service is not recommended. *Coffee service below 150 degrees F will likely result in complaints of cold coffee and will not eliminate the risk of burns. *To help mitigate the risk of burns, ensure adequate monitoring and assistance is available to residents Record review of the facility policy for accident intervention, last revised May 2007, stated: .It is the policy of this facility that the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent accidents . .Procedures: 1. Assess resident fully. 2. Provide needed emergency care . .3. Notify physician immediately and responsible party by telephone. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 16 of 17 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 676048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 1201 Fm 2685 Gladewater, TX 75647 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 4. Minor injuries may be reported to physician and responsible party at the earliest appropriate hour. Level of Harm - Immediate jeopardy to resident health or safety 5. Document - notification of physician and orders received notification of family incident report - complete nurses notes Residents Affected - Few 6. Follow up - assess resident during each shift - at least once. Document findings for seventy-two (72) hours 7. Report- 24 hours report. Pass information on in shift report The Administrator was notified of an IJ on 09/12/23 at 2:06PM and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 09/13/23 at 11:00AM and included the following: [Facility Name] F689 Plan of Removal 09/12/23 Per the information provided in the IJ Template given on 09/12/23 at 1409, the facility failed to temp the coffee prior to giving it to the residents and failed to assess resident abdomen immediately. The facility failed to have a policy to ensure coffee temps were at the appropriate temperature. The facility failed to follow the elopement policy and the facility failed to ensure the alarm on the exit door on hall 400 was turned on. 1. The Medical Director was notified of IJ on 09/12/23 1425. 2. Skin sweep of total census initiated 09/12/23 and will be completed 09/12/23 by Clinical Resources, Clinical Le[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 17 of 17