Health inspection·January 24, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few year-old male and admitted on [DATE] and 05/28/23 with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis ( one-sided muscle weakness) following subarachnoid hemorrhage affecting left non-dominant side, need for assistance with personal care, muscle weakness, reduced mobility, abnormalities of gait and mobility, muscle wasting and atrophy (shortening). Record review of Resident #33's annual MDS assessment dated [DATE] indicated Resident #33 was usually understood and usually had the ability to understand others. The MDS indicated Resident #33 had minimal difficulty hearing with no hearing aid, adequate vision, and clear speech. The MDS did not indicated Resident #33's BIMS score. The MDS indicated Resident #33 required substantial/maximal assistance for toileting, oral, personal hygiene, shower/bathe self, chair/bed-to-chair transfer, toilet transfer, lying to sitting on side of bed, and sit to stand. The MDS indicated Resident #33 was always incontinent of urine and bowel. Record review of Resident #33's care plan dated 06/28/23 indicated Resident #33 was at risk for falls related to impaired balance, weakness, cardiac meds, insulin use, and CVA with hemiplegia. Intervention included, be sure the call light was within reach and encourage to use it to call for assistance as needed. During an interview and observation on 01/23/24 beginning at 9:19 a.m., Resident #33 and Resident #16 were in their beds. Resident #33's call light was draped over his nightstand with the button facing the ground. Resident #33 said he could not reach it and did not know how long it had been on the nightstand. Resident #33 said he guessed he had not had to use it yet. Resident #16 was sitting up in bed with a hand brace on his left hand. Resident #16's call light was hanging down the right side of his bedrail. Resident #16 said he could not reach it. Resident #33 said they took care of each other by call for help for each other when one of their call lights were not within reach. During an interview on 01/24/24 at 10:15 a.m., CNA N said CNAs were responsible for resident's call lights being within reach. She said when resident's call lights were not within reach, it was neglect. She said call lights were needed if a resident needed to get help. During an interview on 01/24/24 at 11:33 a.m., CNA P said she was assigned Resident #16 and Resident #33 on 01/22/24 and 01/23/24. She said nurse and aides were responsible for making sure resident's call lights were within reach. She said Resident #33's clip on the call light did not work so if he moved the head of the bed up or down, it slipped off the bed. She said she did notice Resident #16's call light hanging down the right side of the bedrail. She said when resident's call lights were not within reach, falls could happen. She said Resident #16 got confused and tried to get up and walk. She said Resident #16 and Resident #33's call light may not always be within reach, but the facility staff left their door open and constantly checked on them. During an interview on 01/24/24 at 12:16 p.m., RN M said CNAs and LVNs were responsible for making sure resident's call lights were within reach. She said she ensured resident's call lights were within reach by making rounds and asking the resident if they had it. She said when a resident's call light was not within reach, residents cannot get help and would have to holler out. During an interview on 01/24/24 at 12:41 p.m., ADON said all staff were responsible for ensuring resident's call lights were within reach. She said management did angel rounds daily to make sure the call lights were working and should be making sure they were within reach. She said when call lights were not within reach, staff would not know if residents needed something. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 2 of 35 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 01/24/2024 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 01/24/24 at 1:06 p.m., the DON said all staff members should make sure resident's call light should be within reach. She said upper management made rounds to monitor call light placement. She said when call lights were not within reach, residents could not get help. During an interview on 01/24/24 at 1:32 p.m., the ADM said he expected resident's call lights to be within reach. He said everyone was responsible for making sure call lights were within reach. He said they did angel rounds every morning to ensure call light placement. He said when resident's call light was not within reach, it had the potential to put a resident in situation to not be able to ask for what they needed. Record review of a facility's Call Lights policy/procedure revised 06/07 indicated .it is the policy of this facility to provide the resident a means of communication with nursing staff .place the call device within resident's reach before leaving room . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 3 of 35 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 01/24/2024 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, and misappropriation of resident property and establish policies and procedures to report and investigate such allegations, for 1 of 7 staff (RN T) reviewed for abuse/neglect. Residents Affected - Few The facility's staff members (LVN D, RN H, LVN Q, LVN R, CNA K, CNA U, CNA N) failed to immediately report RN T suspicious behaviors and behaviors that may indicate an impaired individual to the ADM and DON. The facility hired RN T, who had active disciplinary action against her nursing license per the Texas Board of Nursing, which was against their policy. These failures could place residents at risk of abuse and neglect. Findings included: Record review of the facility's provider report dated 09/28/23 indicated .at approximately 2:05 p.m. 09/20/23 ADON was conducting a routine electronic medication administration record [eMAR] and narcotic count logs review .during the audit ADON identified discrepancies with multiple nurses documenting the administrator of PRN meds in the eMAR and the narcotic count logs .ADON identified that three residents on the 400 hall (Resident #165, Resident #16, Resident #33) had excessive signatures from one particular nurse .confirmation of the narcotic administration discrepancy was confirmed when ADON interviewed Resident #165 .and she [Resident #165] stated she had not received the pain medication documented on the narcotic log .at this point .ADON notified the DON and ADM of a possible drug diversion .the nurse in question, RN T, was suspended at 2:20 p.m. pending investigation .RN T instantly stated that her coworkers 'had it out for her' and she knew the must have done something to trigger the allegations .the DON received a call from LVN V .LVN V stated that she had noticed that the nurse she usually follows [RN T] rarely signs out PRN medication in the eMAR but did sign out them out on the narcotic log .interviews of RN T's coworkers were conducted .the interviews revealed that most have observed recent behavioral changes in nurse [RN T] which were described as 'extremely energetic followed by excessive drowsiness .RN T suspension ended in termination on 09/28/23 . Record review LVN D's undated interview, in the facility's provider report dated 09/28/23, indicated .Have you ever had any concerns related to any coworkers and medication administration? .Yes .Just some observations over the past 3 to 4 weeks .Have you ever been concerned with any behaviors by your coworker? .Yes I have .Please explain .one nurse behavior in particular (referring to RN T) has become extremely paranoid .we were having a personal conversation and she informed me that her future ex had filed charges against her in court regarding use of pills . a few weeks later we were having another conversation and I [LVN D] had made a joke about her ex's allegations and she became extremely defensive and paranoid asking what I knew .after that she has shown a lot of paranoia .she had had slurred words and her movements have seemed very purposeful .Do you feel like her ability to care for residents was effected by these recent changes in behavior? .absolutely .Have you ever felt like she was under the influence while she was at work? .several times over the past few weeks .Did you report your suspicious to anyone? . No, I did not. I thought maybe she was taking something at home . Record review of LVN Q's undated interview, in the facility's provider report dated 09/28/23, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 4 of 35 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 01/24/2024 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated .Have you ever had any concerns related to any coworkers and medication administration? . I have concerns about [RN T]. I had an alert and oriented resident that stated he didn't think he was getting PRN medication .Has there ever been any issues with narcotic count at shift change? .I have had issues with [RN T] not signing meds out in the MAR but it is signed out on the narcotic log .Why do you believe I am asking questions about medication administration? .I have noticed [RN T] has been signing out a lot more pain medications than I have seen . Have you ever been concerned with any behaviors by your coworker? . When she comes in the morning she is quite alert but when I come back at night she is overly drowsy .Does this happen often or has the frequency increased? .It's increased most definitely .initially it wasn't that bad .since moving to 400 hall I am noticing it a lot more . Do you feel like her ability to care for residents was effected by these recent changes in behavior? . Most definitely . Have you ever felt like she was under the influence while she was at work? . Yes .Did you notify anyone? .I did not .In the future will you notify someone? .Absolutely .I try to give my coworkers the benefit of the doubt but realize I probably shouldn't have done that .Do you know who to notify in the future should you suspect someone is under the influence .You (referring to DON) . Record review of RN H's undated interview, in the facility's provider report dated 09/28/23, indicated .Have you ever been concerned with any behaviors by your coworker? . Yes .[RN T] .seemed more drowsy .more quiet, droopy eyes, unable to maintain eye contact, zone out during conversations . Do you feel like her ability to care for residents was effected? . I thinks so in terms of there were people coming and saying they hadn't had their medications .I found medications left in the cart before .Did you notify anyone when you thought she was under the influence? . No, I didn't know if it was prescription or something from her injury . Do you know who to notify in the future should you suspect someone is under the influence .Yes, the DON . Record review of LVN R's undated interview, in the facility's provider report dated 09/28/23, indicated .Have you ever had any concerns related to any coworkers and medication administration? . Yes . Has there ever been any issues with narcotic count at shift change? . Once when I took over from her and the count was off . Why do you believe I am asking questions about medication administration? . Um because of my coworkers behavior and the way she talks to people and the way she looks .She is really hyper one minute, cleaning the med room early in the shift then 2 or 3 more times, then later is extremely drowsy .she goes outside a lot and her eyes will be closed or rolling back in her head while she is have a conversation .Have you ever reported your suspicions to anyone? .Yes .I told [LVN W] last month that I thought she was under the influence because she couldn't keep her eyes open . Do you know who to notify in the future if you believe a coworker is under the influence while working? . Yes, the DON, the ADM or Compliance . Record review of CNA K's undated interview, in the facility's provider report dated 09/28/23, indicated .Have you ever noticed any nurse acting different? . Yes. [RN T]. She sometimes slurs her words and is extremely drowsy . Record review of CNA N's undated interview, in the facility's provider report dated 09/28/23, indicated .Have you ever noticed any nurse acting different? . Yes, [RN T] would be really drowsy and falling asleep or lazy eyed at the nurses station and medication cart .she acts different at times, acts suspicious . [RN T] would hesitate and wait to administer medications to residents until I left the room .Did any resident complain of not getting medication? . Yes . [Resident #165] complained that she didn't get her medication. When I reported it to [RN T], she said she gave it to her an hour ago .another resident would still complain of pain and reported that she didn't get her pain medication .when I followed up with [RN T], she said she already gave it to her . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 5 of 35 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 01/24/2024 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of CNA U's undated interview, in the facility's provider report dated 09/28/23, indicated .Have you ever noticed any nurse acting different? . Yes .Can you name the nurse? . [RN T], it was like she wasn't awake all the way . Record review of RN T's Counseling/Disciplinary Notice dated 09/20/23 indicated .date of hire 04/07/23 .suspension, pending investigation, subject to discharge .reason .allegation of drug diversion .DON 09/22/23 . Signature of Witness (if employee refuses to sign) .ADM . During an interview on 01/23/24 at 10:15 a.m., the ADON said she was responsible for auditing documentation and administration of narcotic medication. She said she was out on leave June 2023 until the end of August 2023 and did not know if anyone did audits in her absence. She said when she returned from leave, she performed an audit and notice discrepancies on some resident's PRN narcotic administration. She said after further investigation of the discrepancies noted in August and September 2023, she identified 3 residents and RN T was involved with. She said LVN A said Resident #165 said she only needed her PRN pain medication at night but there was documentation of her receiving dose during the day. She said nurses were required to document narcotic administration on the eMAR and narcotic log. She said there were several administrations not done correctly by RN T. She said the narcotic count was always correct. She said nursing staff had drug diversion and abuse training upon hire and regularly through a computer program provided by the facility. She said staff members should have reported RN T's suspicious behavior and incorrect documentation for resident's PRN narcotics. She said staff who noticed RN T's behaviors and did not report received 1:1 counseling and all staff were given in-services and the drug diversion policy reread to them. She said she knew RN T had stipulations on her license but did not know the details. She said there had been reports from another facility that RN T had been fired for similar behaviors and allegations. During an interview on 01/23/24 at 10:30 a.m., the DON said the ADON noticed the trend of RN T documenting narcotic administration on the narcotic log but not the eMAR. She said Resident #165 was not known to taking her prn pain medication frequently but when RN T worked, she had a lot logged on the narcotic log. She said an audit was performed on residents with prn pain medications in September 2023, and a pattern was found. She said all nurses were drug tested during the investigation. She said the facility did not have a schedule on when to do narcotic log audits. She said the DON and the ADON were responsible for doing the audits. She said during the ADON's leave, a narcotic administration audit was not done. She said no staff members expressed concerns about RN T's charting or behavior. She said staff knew they were supposed to report concerns to upper management. She said she did not know why they did not report their concerns. She said a drug diversion could not be confirmed because RN T's drug test was negative, and Resident #165 had attention seeking behaviors so they could not be sure she was telling the truth. She said the facility could only prove RN T did not follow proper procedure for documenting narcotic administration. She said RN T was hired with known stipulation on her license. She said RN T had attendance counseling in September 2023. She said RN T's stipulation orders were still active and in place. She said after the investigation staff were educated on reporting and change of staff behavior. She said she did not know if the facility reported RN T's allegations to the BON. During an interview on 01/23/24 at 10:51 a.m., the ADM said he was the abuse coordinator. The ADM said the ADON returned from leave and did an audit of the narcotic logs and noticed medication discrepancies. He said the ADON spoke to the resident affected by the discrepancies, and they expressed not receiving some of the entries list. He said staff members said RN T had a change in her behavior but had not said anything. He said he was only aware of RN T's stipulation on her nursing license from the DON but did not know the details. He said he had to give RN T's her drug test at home so he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 6 of 35 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 01/24/2024 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few felt the sample could not have been altered. He said her drug test results were negative and investigation unconfirmed, so the facility did not refer her license. He said RN T was suspended then terminated due to the strong coincidences. On 01/23/24 at 12:30 p.m., attempted to contact RN T, voicemail left to return phone call. No return phone call was received before or after exit. On 01/23/24 at 12:40 p.m., attempted to contact LVN D, voicemail left to return phone call. During an interview on 01/23/24 at 1:00 p.m., LVN A said she had noticed a resident getting more prn pain medication than normal. She said she never worked with RN T but worked alternate shifts with her. She said no residents every complained about not getting their pain medications. She said she noted the extra administration and when the initial investigation started, she mentioned her findings to the ADON. On 01/23/24 at 3:08 p.m., attempted to contact LVN Q, voicemail left to return phone call. On 01/23/24 at 3:11 p.m., attempted to contact RN H, voicemail left to return phone call. During an interview on 01/23/24 at 3:15 p.m., RN H stated she had been employed at the facility since March 2021. RN H said she worked 6am-6pm shift on the 300 hall. She said the facility required PRN narcotic medication administration had to be documented on the eMAR and narcotic log. She said she knew to let the DON know if a resident reported they did not get their medications. She said she had noticed RN T being drowsy or possible being under the influence. She said other staff members had noticed her strange behavior and were talking about that amongst themselves. She said she did not report her concerns of RN T, but she thought it had already been reported. She said after audit results, the facility did an in-service on signing PRN medication in both places. She stated not reporting her concerns, if the resident was not getting their medications, they would not be getting proper care. She said the ADM was the abuse coordinator. During an interview on 01/24/24 at 10:57 a.m., LVN D said RN T had a change in her behavior. He said RN T started slurring her words and fidgeting. He said he mentioned to RN T that she was looking suspicious that if she was taken prescribed medication, she could not come to work looking drowsy. He said he thought he had discussed his concerns with the ADON but maybe it was the DON because the ADON was on leave. He said 1 or 2 weeks after he mentioned her changed behavior, she was suspended. He said RN T had missed a few days of work and texted him she had fallen and broke a part of her body. He said it was odd because later she texted him, the doctor had sent her home. He said he and other nurse had been talking amongst themselves for 3 to 4 weeks of RN T behavior change. He said in a 3-4 weeks period was 1 week before the before the audit was done and 2-3 weeks while RN T was being investigated. He said he felt like he notified management of his concerns in a timely manner. He said RN T did not char her administration of the narcotics given until the end of the shift. He said the facility required documenting on the eMAR and narcotic sheet. He said documenting in each place was for accountability and if not done caused discrepancies. He said staff received training on when to sign medication and documenting, and drug diversion. On 01/24/24 at 11:32 a.m., attempted to contact LVN R, voicemail left to return phone call. No return call before or after exit. During an interview on 01/24/24 at 11:33 a.m., CNA P said she had been employed at facility since (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 7 of 35 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 01/24/2024 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few September 2022. She said she worked the 400-hall. She said she did work with RN T. She said RN T said inappropriate things and was not readily available. She said she did not really notice drowsy or suspicious behaviors. She said she knew to report concerns about medications to the ADON or DON, and abuse and neglect concerns to the ADM. On 01/24/24 at 12:09 p.m., attempted to contact LVN Q, voicemail left to return phone call. No return call before or after exit. During an interview on 01/24/24 at 12:41 p.m., the ADON said staff not reporting drug diversion or staff members behavior concerns placed resident at risk to go without their pain medication. She said improper documenting prn medication could lead to medication errors, drug diversion, and potential overdose of the resident. She said auditing narcotic administration and documenting was still not a scheduled task after the incident. She said she did perform more audits than she used to after the incident with RN T. She said she was not a 100 percent sure because she was not working at the time, but she believed staff had reported RN T's impaired behavior and suspicions to upper management before the investigation. During an interview on 01/24/24 at 1:06 p.m., the DON said she was not informed of RN T's changed behavior before the incident was investigated. She said staff did not start mentioning their concerns with RN T's behavior until the investigation started. She said staff not reporting their concerns risked resident not getting their pain medications, staff working impaired, or medication administered inappropriately. She said RN T has stipulations to work and she followed those stipulations. She said RN T's reprimand with stipulations from the BON was not a disciplinary action on her license. She said a disciplinary action on her license would be if it was suspended or revoked. She said she hired RN T. She said RN T was hired in April 2023 and issues did not start until September 2023. During an interview on 01/24/24 at 1:32 p.m., the ADM said management did not have knowledge of the staffs concerns about RN T's behavior. He said staff should have immediately reported their concerns to the DON or ADM. He said not reporting potential to put resident at risk for abuse or neglect. He said the facility did have a policy which stated if staff had a suspicion of drug diversion or impairment of another staff member, it was supposed to report immediately. He said the DON hired RN T, so he did not know her stipulation ordered facility to report similar allegation to the BON. He said did not know if RN T's stipulation was considered a disciplinary action against her license. Record review of a facility's Narc med administration in-service training report dated 04/26/23, presented by DON and ADON, indicated .you must sign out narc medications in the narc book as soon as you pop medications out of blister pack .do not wait until the end of the shift .all prn narc medications MUST be signed out as soon as it is administered .you MUST also click off PRN medication on the EMAR .if you fail to do this it is drug diversion and could lead to termination . RN T's signature was not noted but RN H, LVN Q,LVN A, and LVN V was. Record review of a facility's Abuse and Neglect in-service training report dated 06/22/23, presented by LVN W, indicated .Resident Rights .Abuse: Prevention of and Prohibition Against policy . RN T, LVN A, LVN D, CNA U, RN H, LVN Q, and LVN R signature was noted. Record review of a facility's Pre-pull medications in-service training report dated 09/05/23, presented by DON and ADON, indicated .policy .do not pre-pull medications .you must administer the medications to the resident as soon as you remove it from the blister pack .pre pulling is not acceptable .you are more at risk for medication error .if you pre-pull, then it could result in disciplinary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 8 of 35 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 01/24/2024 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 0607 action . RN T signature was not noted. Level of Harm - Minimal harm or potential for actual harm Review of Texas Board of Nursing Discipline & Complaints, Notice of Disciplinary Action 07/21, www.bon.texas.gov/discipline_and_complaints_disciplinary_action_072021.asp.html was accessed on 01/24/24 revealed .the following nurses had disciplinary action taken against their licenses through a Board order containing public information about the nurse's disciplinary action .RN T .Discipline: Reprimand with Stipulations .Date of Action: 03/23/21 . Residents Affected - Few Record review of a facility's Drug Diversion Reporting an Response policy and procedure revised on 01/22 indicated . it is the policy of this facility to provide guidelines for the identification and reporting of suspected drug diversion by employees or other individual .suspicion of dug diversion may arise from variety of circumstances including .behaviors that may indicate an impaired individual .suspicious activity identified during routine monitoring or proactive surveillance .any employee who suspects that drug diversion has occurred should immediately notify the ADM and DON . Record review of a facility's undated Administration and Documentation of Controlled Medications policy indicated .document in the appropriate area on the MAR or eMAR .document on the narcotic count down sheet provided for each individual substance . Record review of a facility's Abuse: Prevention of and Prohibition Against policy revised 10/22 indicated it is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property .the facility will provide oversight and monitoring to ensure that its staff .deliver care and services in a way that promotes and respects the rights of the resident to be free from abuse, neglect, misappropriation of resident property .identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur, to include validating that the Facility has deployed the correct number of competent staff on each shift .facility staff with knowledge of an actual or potential violation of this policy must report the violation to his or supervisor or the facility administrator immediately .all allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the Administrator . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 9 of 35 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 01/24/2024 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure BIMS assessments accurately reflected the status for 3 of 16 residents reviewed for assessments. (Resident #'s 28, 33, and 45) Residents Affected - Some 1.The facility failed to ensure Resident #45's admission MDS assessment dated [DATE] and his Quarterly MDS assessment dated [DATE] accurately reflected his cognitive status. 2.The facility failed to ensure the Resident #28's Quarterly MDS assessment dated [DATE] accurately reflected her cognitive status. 3.The facility failed to ensure the Resident #33's Annual MDS assessment dated [DATE] accurately reflected his cognitive status. This failure could place residents at risk of not having individual needs met. Findings included: 1. Record review of the undated face sheet indicated Resident #45, a [AGE] year-old male admitted [DATE]. Record review of the consolidated physician's orders dated 1/22/24 indicated Resident #45 had diagnoses including: dementia (impairment of at least 2 brain functions, such as memory loss and judgement), chronic systolic congestive heart failure (the heart cannot pump enough blood to provide the body with the blood and oxygen it needs), chronic pulmonary embolism (blockage of an artery in the lungs), and constipation (passing less than three bowel movements a week). Record review of the admission MDS dated [DATE] indicated Resident #45 had minimal difficulty hearing, clear speech, was understood by others, and understood others. Section C, C0100 Should brief interview for Mental status be conducted? This was marked 1 indicating Yes. The BIMS interview was dashed meaning there were no scores on his cognitive abilities. Record review of the Quarterly MDS dated [DATE] indicated Resident #45 had minimal difficulty hearing, clear speech, was understood by others, and understood others. Section C, C0100 Should brief interview for Mental status be conducted? This was marked 1 indicating Yes. The BIMS interview was dashed meaning there were no scores on his cognitive abilities. Record review of the undated care plan indicated Resident #45 was at risk for impaired cognitive function related to dementia. The care plan indicated he had congestive heart failure and constipation. The care plan indicated he was at risk for a communication problem related to a hearing deficit. Record review of an IDT - BIMS dated 11/7/23 indicated Resident #45 had a BIMS score of 14 indicating he was cognitively intact. Record review of an IDT - BIMS dated 12/11/23 indicated Resident #45 had a BIMS score of 13 indicating he was cognitively intact. During an interview on 01/22/24 at 12:57 PM, the MDS nurse said she would check to see why there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 10 of 35 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 01/24/2024 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some were no BIMS scores on Resident #45's admission or Quarterly MDS's She said it must not have been done timely, meaning the BIMS assessment was not completed in the 7-day lookback period. During an interview on 01/22/24 at 2:38 PM, the MDS nurse said it was her responsibility to get the BIMS assessment done within the 7-day look back period and it must have been missed. She said the BIMS assessment for Resident #45 could not be put in the quarterly MDS assessment dated [DATE] because it was 2 days out of the 7 day look-back period, so it was too late. She said she may have missed the BIMS dates on both Resident #45's assessments, his admission and his quarterly. She said she could not remember why she missed doing the BIMS assessments on time. She said she did double check herself and the corporate person checked to make sure she had done them. She said corporate was aware she had done them late. She said there were probably others that were late. She said it was up to her or the SW to do the BIMS assessments on residents. She said the BIMS score not being recorded on the MDS should not have any negative effect on a resident. During an interview on 01/23/24 at 8:12 AM, the SW said she completed the BIMS assessments then puts them in the computer under assessments. She said then the MDS nurse puts those assessments in the MDS assessment. She said that was the process. The SW said Resident #45's quarterly MDS was opened on a Saturday, 12/9/23 and she only worked Monday through Friday so she could not do the BIMS assessment that day. She said she realized the MDS was opened on Monday 12/11/23 and did the BIMS that day which made it too late to go on the MDS assessment. She said she was not aware it was due until she came in on Monday 12/11/23. She was looking in her computer and said the admission BIMS was 10/18/23 and that BIMS was done by the ST at the time. She said the second BIMS for Resident #45 was 11/7/23 and done by her. She said she did the third BIMS on 12/11/23. She said the ARD was 12/9/23 and was not completed until 12/11/23. She said it was completed late because she did not know it was opened. She said the BIMS for the admission MDS for Resident #45 was done 10/27/23 and it was done too early (more than the 7-day look back). She said it was the responsibility of the MDS nurse to make sure the BIMS assessment was done timely. She said no one other than her or the MDS nurse checked to see if the MDS or sections of the MDS were completed on time. She said the MDS nurse answered to someone in corporate. She said no one ever brought to her attention that parts of the MDS were late. During an interview on 1/23/24 at 10:02 AM, the Corporate MDS Resource Nurse said they did audits periodically to make sure the MDS's were completed. She said if an MDS was not done properly they would provide education to the MDS nurse. She said all MDS's should be done properly, with the BIMS assessments filled out. She said if the BIMS assessment was not completed before the ARD date, it could not put it in the MDS per the RAI [NAME]. She said if an ARD was Saturday and the BIMS had not been done it would have to be dashed in the MDS and then a BIMS would still have to be done to update the plan of care. She said the MDS nurse was responsible for making sure the MDS was filled out properly and complete with the BIMS scores. She said she was responsible for making sure the MDS nurse had done them properly. She said she was not aware there were MDS's that were completed without the BIMS scores. She said she did not do daily audits. She said there was a potential problem with their process, but she would have to see how many MDS's had not been completed and whether it was a few or a lot. She said she would have to check on it before she could say if there was a problem with their process. During an interview on 1/23/24 at 2:22 PM, the MDS nurse said she could not recall if they had a process for checking to make sure the BIMS assessments were done in an appropriate time frame to be put on the MDS admission and quarterly assessments at the times Resident #45 had his admission and quarterly assessments done. (October and December of 2023) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 11 of 35 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 01/24/2024 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 1/24/24 at 10:48 AM, the ADON said she expected the BIMS assessments to be done in a timely manner so that it could be put on the MDS assessment. She said there were BIMS assessments under assessments for Resident #45. During an interview on 1/24/24 at 10:56 AM, the DON said she expected the BIMS assessments to be done timely so that it was on the MDS assessment. She said the MDS nurse was responsible for making sure that was done. She said she did not know why the MDS nurse did not get the BIMS assessments on the MDS's. She said the Corporate MDS Resource Nurse oversaw her. She said there were BIMS assessments in the record for Resident #45. During an interview on 1/24/24 at 11:03 AM, the ADM he expected the BIMS assessments to be done in a timely enough manner to make it on the MDS assessment. He said there were BIMS assessments in the charts. He said the MDS nurse was responsible for making sure that was done. 3. Record review of Resident #33's face sheet printed 01/22/24 indicated Resident #33 was an [AGE] year-old male and admitted on [DATE] and 05/28/23 with diagnoses including vascular dementia (is a decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain, depriving them of oxygen and nutrients) and cognitive communication deficit (in difficulty with thinking and how someone uses language). Record review of Resident #33's annual MDS assessment dated [DATE] indicated Resident #33 was usually understood and usually had the ability to understand others. The MDS indicated Resident #33 had minimal difficulty hearing with no hearing aid, adequate vision, and clear speech. The MDS did not indicated Resident #33's BIMS score. The MDS indicated Resident #33 required substantial/maximal assistance for toileting, oral, personal hygiene, shower/bathe self, chair/bed-to-chair transfer, toilet transfer, lying to sitting on side of bed, and sit to stand. The MDS did not indicated Resident #33's BIMS score. Record review of Resident #33 care plan dated 11/08/22 indicated Resident #33 was at risk for impaired cognitive function/dementia or impaired thought processes. Intervention report to nurse any changes in cognitive function, specifically changes in decision making ability, memory, recall, awareness of surroundings and others, difficulty expressing self, difficulty understanding others, sleepiness/lethargy, and confusion. During an interview on 1/24/24 at 10:01 AM, the Regional Nurse emailed me that they did not have an Accuracy of Assessments policy or an MDS policy. She said they use the RAI Manual. During an interview on 01/24/24 at 3:00 p.m., the MDS coordinator said she was not aware Resident #33's BIMS assessment score was missing from his MDS. She said she did not know why it was not done but the facility had done an audit yesterday (01/23/24), after being made aware that some resident did not have BIMS scores on their MDS. 2. Record review of Resident #28's quarterly MDS assessment, dated 12/20/23, indicated Section C, C0100 Should brief interview for Mental status be conducted? This was marked 1 indicating Yes. The BIMS interview was dashed meaning there were no scores on her cognitive abilities. Record review of Resident #28's undated care plan indicated she was at risk for impaired cognitive function related to dementia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 12 of 35 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 01/24/2024 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of an IDT - BIMS dated 12/26/23 indicated Resident #28 had a BIMS score of 15 which indicated she was cognitively intact. During an interview on 01/24/24 at 10:40 AM, the MDS Nurse said Resident #28's 12/20/23 Quarterly MDS was missing the BIMS assessment because the ARD date was 12/20/23 and the BIMS assessment was not completed until 12/26/23. She said was unable to add the assessment at that time to the MDS because the MDS had closed. she said it was missed and she should have caught it. Event ID: Facility ID: 676048 If continuation sheet Page 13 of 35 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 01/24/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 of 16 residents (Residents #16 and Resident #33), reviewed for care plans. 1.The facility failed to revise and update Resident #16's comprehensive care plan for his functional abilities related to shower/bathing and eating. 2.The facility failed to revise and update Resident #33's comprehensive care plan for his functional abilities related to eating, shower/bathing, and personal hygiene. These failures could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: 1. Record review of Resident #16's face sheet printed 01/22/24 indicated Resident #16 was a [AGE] year-old male and admitted on [DATE] and 11/08/23 with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following nontraumatic intracerebral hemorrhage (spontaneous bleeding into the brain tissue) affecting left non-dominant side, need for assistance with personal care, muscle weakness, reduced mobility, abnormalities of gait and mobility, muscle wasting and atrophy (shortening). Record review of Resident #16's quarterly MDS assessment dated [DATE] indicated Resident #16 was usually understood and usually had the ability to understand others. The MDS indicated Resident #16 had unclear speech and impaired vision. The MDS indicated Resident #16 had a BIMS score of 07 which indicated severe cognitive impairment. The MDS indicated Resident #16 had functional limitation in range of motion on one side of the upper and lower extremities. The MDS indicated Resident #16 was dependent for toileting hygiene, shower/bath self, personal hygiene, and chair/bed-to-chair transfer and setup or clean-up assistance for eating. Record review of Resident #16's care plan dated 08/11/23 indicated Resident #16 had an ADL self-care performance deficit related to stroke. Interventions included transfer requires 1 staff participant with transfers, bed mobility: requires 1 staff participant to reposition and turn in bed, personal hygiene/oral care x1, dressing: requires 1 staff participation to dress, and transfer: requires Hoyer lift x2 staff with transferring. The care plan did not indicate Resident #16's functional abilities for eating and shower/bathing. Record review of Resident #16's care plan dated 10/27/23 indicated: * Resident #16 had swallowing problem related to coughing or choking during meals or swallowing med, and difficulty with thin liquids. *Resident #16 had weight loss related to poor food intake. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 14 of 35 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 01/24/2024 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 0657 Review of the care plan did not reflect Resident #16's functional abilities for eating. Level of Harm - Minimal harm or potential for actual harm 2. Record review of Resident #33's face sheet printed 01/22/24 indicated Resident #33 was an [AGE] year-old male and admitted on [DATE] and 05/28/23 with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following subarachnoid hemorrhage affecting left non-dominant side, need for assistance with personal care, muscle weakness, reduced mobility, essential tremors, abnormalities of gait and mobility, muscle wasting and atrophy (shortening). Residents Affected - Few Record review of Resident #33's annual MDS assessment dated [DATE] indicated Resident #33 was usually understood and usually had the ability to understand others. The MDS indicated Resident #33 had minimal difficulty hearing with no hearing aid, adequate vision, and clear speech. The MDS did not indicated Resident #33's BIMS score. The MDS indicated Resident #33 required substantial/maximal assistance for toileting, oral, personal hygiene, shower/bathe self, chair/bed-to-chair transfer, toilet transfer, lying to sitting on side of bed, and sit to stand and supervision or touching assistance for eating. Record review of Resident #33's care plan dated 11/08/22 indicated Resident #33 had ADL self-care performance deficit related to recent hospitalization with CABG (is a surgical procedure used to treat coronary heart disease), CVA (a stroke), CHF (is a long-term condition in which your heart can't pump blood well enough to meet your body's needs), and chest pain. Interventions included eating: independent with setup and toilet use, transfer, bed mobility, and dressing physical assist x1. Review of the care plan did not reflect Resident #33's functional abilities for shower/bathe self and personal hygiene. During an interview on 01/24/24 at 10:15 a.m., CNA N said staff can view the care plan on the facility's electronic charting system. She said the care plan told the resident's assistance level. She said if the assistance level was not on the care plan, she asked the nurse about their care needs. She said Resident #16 required assistance with eating. She said Resident #33 required setup for eating. She said if the care plan was not updated or revised the resident could get the wrong care. During an interview on 01/24/24 at 11:33 a.m., CNA P said she thought on the resident's eMAR, the care plan information could be seen. She said nursing staff walked and assessed the resident to know how to take care of the resident and know their assistance level. She said for Resident #16, she had to assistance him with eating and he occasional fed himself. She said if the resident's assistance level could not be found or changed, the nurse updated them. She said if the care plan had the wrong assistance required or no assistance noted the resident could not get the correct care and hurt the resident. During an interview on 01/24/24 at 12:16 p.m., RN M said staff were able to see the resident's care plan on the computer. She said she determined the resident's level of assistance by observation. She said if the care plan did not match the resident's MDS assistance level, the resident may not get what they needed. She said the resident's ADL abilities should be care planned. During an interview on 01/24/24 at 12:41 p.m., the ADON said the nurse and MDS coordinator revised/updated care plans. She said if a resident received the wrong level of assistance for ADLs, it could hurt the resident's progress. She said any nurse could update the care plan, but a RN had to oversee and add new care plan problems. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 15 of 35 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 01/24/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm During an interview on 01/24/24 at 1:06 p.m., the DON said the MDS coordinator was responsible to revise and update care plans. She said care plan were random checked for accuracy but there was no specific time or person. She said she expected a resident's ADL care assistance to be care planned but if the resident was on rehab their assistance may change. She said the resident's care plan provided information on how to take care of the resident. A care plan policy regarding revision was requested. Residents Affected - Few During an interview on 01/24/24 at 3:00 p.m., the MDS coordinator said she revised care plans with input from the IDT. She said she normally care planned ADL care of eating, transfer, and toileting needs. She said she thought she did bathe too. She said if the wrong ADL assistance was provided to a resident, they may not get the care needed. She said Resident #16's eating assistance was important because he had weight loss. She said she was not aware Resident #16 and Resident #33 did not have some care areas care planned. On 01/24/24 at 3:10 p.m., the DON said the facility did not have a care plan policy but followed the RAI manual. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 16 of 35 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 01/24/2024 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 - Minimal harm or potential for actual harm 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 has failed to ensure that the resident environment remains as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 1 of 2 residents reviewed for transfer. (Residents #33) The facility failed to ensure CNA N performed a safe 1 person transfer for Resident #33 due to not using a gait belt during transfer. This failure could place residents at risk of injury from accident and hazards. Findings included: Record review of Resident #33's face sheet printed 01/22/24 indicated Resident #33 was an [AGE] year-old male and admitted on [DATE] and 05/28/23 with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following subarachnoid hemorrhage affecting left non-dominant side, need for assistance with personal care, muscle weakness, reduced mobility, essential tremors, abnormalities of gait and mobility, muscle wasting and atrophy (shortening). Record review of Resident #33's annual MDS assessment dated [DATE] indicated Resident #33 was usually understood and usually had the ability to understand others. The MDS indicated Resident #33 had minimal difficulty hearing with no hearing aid, adequate vision, and clear speech. The MDS did not indicated Resident #33's BIMS score. The MDS indicated Resident #33 required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds or supports trunk or limbs and provides more than effort.) for chair/bed-to-chair transfer, toilet transfer, lying to sitting on side of bed, and sit to stand. Record review of Resident #33's care plan dated 11/08/22 indicated Resident #33 had ADL self-care performance deficit related to recent hospitalization with CABG (is a surgical procedure used to treat coronary heart disease), CVA (a stroke), CHF (is a long-term condition in which your heart can't pump blood well enough to meet your body's needs), and chest pain. Interventions included toilet use, transfer, bed mobility, and dressing physical assist x1. During an observation and interview on 01/24/24 beginning at 10:13 a.m., Resident #33's bedroom door was closed. After knocking and entering, CNA N opened the bathroom door to get Resident #33's wheelchair, which partially blocked the bedroom door from opening, and said she was getting Resident #33 out bed. CNA N had a gait belt (is an assistive device which can be used to help safely transfer a person from a bed to a wheelchair, assist with sitting and standing, and help with walking around) around her chest. After waiting a few seconds to enter the room due to the bathroom door blocking the bedroom door, CNA N was transferring Resident #33 to his wheelchair. CNA N with a gait belt around her chest, was in mid motion of sitting Resident #33 in his wheelchair by one of his arms. During an interview on 01/24/24 at 10:15 a.m., CNA N said Resident #33 was a one person assist x1 transfer. She said she was supposed to use a gait belt for transfers. She said most of the time, she did not use a gait belt to transfer Resident #33. She said he could do a lot without assistance. She said she sometime used the gait belt for half of the transfer. She said the gait belt had stayed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 17 of 35 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 01/24/2024 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 - Minimal harm or potential for actual harm Residents Affected - Few around her chest during the transfer and had not used it at all for Resident #33. She said gait belts was used to hold a resident in case they fell but Resident #33 had never fallen. She said she had a recent checkoff for transfers. During an interview on 01/24/24 at 10:51 a.m., the DOR said CNA received transfer training upon hire and annually. He said the therapy helped train staff on transfers and the ADON trained staff when therapy was not available. He said staff were trained to use the gait belt for transfer and use it the through the whole process for all residents. He said gait belts were important for safety and not to pull on resident's clothes. He said Resident #33 was a one person transfer during therapy with the use of a gait belt. During an interview on 01/24/24 at 1:50 p.m., the DON, with the ADM present, said transfer check off happened upon hire, once a year, and as needed. She said therapy helped with training when staff needed additional help or training. She said she expected staff to use gait belts when transferring residents. She said not using a gait belt during a transfer placed a resident at risk for falls. Record review of CNA N's Transfers Activities-Skills Checklist signed 12/13/23 indicated Procedure: Transfer from bed to wheelchair .assist the resident to sitting position on the side of the bed .apply transfer belt .hold the transfer belt from underneath, straighten your hips, and legs slightly and lift the client .lower the resident into the wheelchair by flexing your hips and knees .Transfer Activities-Skills Checklist Requirements Met . Record review of a facility's Quality of Care: Transfers, Types of policy/procedure revised 11/07 indicated .Sit to Stand to Chair .place gait belt around the resident .stand facing the resident .block the resident's feet and knew .grasp the gait belt .Bed to Chair (to bed) Minimal Assist Pivot Transfer .resident slides to edge of bed, placing feet apart, flat on floor .stand at resident's weak side, supporting his weak arm with one hand and grasping the safety belt with the other . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 18 of 35 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 01/24/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #16's face sheet printed 01/22/24 indicated Resident #16 was an [AGE] year-old male and admitted on [DATE] and 11/08/23 with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following nontraumatic intracerebral hemorrhage (spontaneous bleeding into the brain tissue) affecting left non-dominant side and heart failure (is a condition that develops when your heart doesn't pump enough blood for your body's needs). Residents Affected - Some Record review of Resident #16's quarterly MDS assessment dated [DATE] indicated Resident #16 was usually understood and usually had the ability to understand others. The MDS indicated Resident #16 had a BIMS score of 07 which indicated severe cognitive impairment. The MDS indicated Resident #16 was dependent for toileting hygiene, shower/bath self, personal hygiene, and chair/bed-to-chair transfer. The MDS indicated Resident #16 used a non-invasive mechanical ventilator (CPAP) while a resident in the last 14 days. Record review of Resident #16's care plan dated 08/15/23 indicated Resident #16 had an altered status related to sleep apnea (is a potentially serious sleep disorder in which breathing repeatedly stops and starts). Intervention included CPAP as ordered. Record review of Resident #16's order summary dated 01/23/23 indicated secure and turn on C-Pap at night, at bedtime for sleep apnea, start date 12/05/23. During an observation on 01/22/24 at 9:30 a.m., Resident #16's CPAP mask was laying on his nightstand not in a bag. 3. Record review of Resident #33's face sheet printed 01/22/24 indicated Resident #33 was an [AGE] year-old male and admitted on [DATE] and 05/28/23 with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following subarachnoid hemorrhage affecting left non-dominant side and obstructive sleep apnea (occurs when the muscles that support the soft tissues in your throat, such as your tongue and soft palate, temporarily relax). Record review of Resident #33's annual MDS assessment dated [DATE] indicated Resident #33 was usually understood and usually had the ability to understand others. The MDS did not indicated Resident #33's BIMS score. The MDS indicated Resident #33 required substantial/maximal assistance for toileting, oral, personal hygiene, shower/bathe self, chair/bed-to-chair transfer, toilet transfer, lying to sitting on side of bed, and sit to stand. The MDS did not indicated use of a non-invasive mechanical ventilator (CPAP) while a resident in the last 14 days. Record review of Resident #33's care plan dated 11/08/22 indicated Resident #33 had altered respiratory status and difficulty breathing related to sleep apnea. Intervention included CPAP as ordered. Record review of Resident #33's order summary dated 01/22/24 indicated CPAP at bedtime, at bedtime related to obstructive sleep apnea, start date 01/18/23. During an interview and observation on 01/22/24 beginning at 9:30 a.m., Resident #33's CPAP mask was laying on his nightstand not in a bag. Resident #33 said staff did not place his CPAP mask in a bag when it was not in use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 19 of 35 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 01/24/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm 4. Record review of Resident #22's face sheet printed on 01/24/24 indicated Resident #22 was a [AGE] year-old female and admitted on [DATE] and 01/26/21 with diagnoses including Huntington's disease (is a rare, inherited disease that causes the progressive breakdown (degeneration) of nerve cells in the brain) and Creutzfeldt-[NAME] disease (is a rare, rapidly worsening brain disorder that causes unique changes in brain tissue and affects muscle coordination thinking, and memory). Residents Affected - Some Record review of Resident #22's quarterly MDS assessment dated [DATE] indicated Resident #22 was usually understood and usually had the ability to understand others. The MDS indicated Resident #22 had a BIMS score of 12 which indicated moderate cognitive impairment. The MDS indicated Resident #22 required partial assistance shower/bathe and oral hygiene and substantial assistance for toileting and personal hygiene. Record review of Resident #22's care plan dated 08/30/22 indicated Resident #22 had potential for alteration in respiratory failure (lungs can't get enough oxygen into the blood) related to hypoxia (is low levels of oxygen in your body tissues, causing confusion, bluish skin, and changes in breathing and heart rate). Intervention included provide oxygen as ordered. During an observation on 01/22/24 at 9:55 a.m., Resident #22's nebulizer mask was on her nightstand, not in use and was not bagged. Record review of Resident #22's order summary dated 01/24/24 indicated Ipratropium-Albuterol Inhalation (is used to treat and prevent symptoms (wheezing and shortness of breath) caused by ongoing lung disease (chronic obstructive pulmonary disease-COPD which includes bronchitis (is an inflammation of the tubes that carry air to and from the lungs) and emphysema (is a type of lung disease that causes breathlessness)) 0.5-2.5 MG/3ML, 1 vial inhale orally two times a day for breathing treatments, start date 01/19/24. 5. Record review of Resident #39's face sheet printed 01/22/24 indicated Resident #39 was a [AGE] year-old male and admitted on [DATE] and 01/04/24 with diagnoses including chronic obstructive pulmonary disease (is a chronic inflammatory lung disease that causes obstructed airflow from the lungs), acute and chronic respiratory failure (is a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide) and cerebral infarction (stroke). Record review of Resident #39's quarterly MDS assessment dated [DATE] indicated Resident #39 was sometimes understood and usually had the ability to understand others. The MDS indicated Resident #39 had a BIMS 09 which indicated moderate cognitive impairment. The MDS indicated Resident #39 was dependent for personal and toilet hygiene and dressing, and shower/bathe self. The MDS indicated pneumonia (is an infection that inflames the air sacs in one or both lungs). The MDS indicated Resident #39 was on oxygen therapy while a resident in the facility within the last 14 days. Record review of Resident #39's care plan dated 11/07/22 indicated Resident #39 had oxygen therapy related to ineffective gas exchange. Intervention included oxygen via nasal cannula. Record review of Resident #39's order summary dated 01/22/24 indicated change oxygen tubing and humidifier bottle every night every Sunday, start date 01/04/24. The order summary did not indicate change or clean oxygen filter. During an observation and interview on 01/22/24 beginning at 10:54 a.m., Resident #39 was sitting up in bed with a nasal cannula on his face connected to an oxygen concentrator. Resident #39's oxygen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 20 of 35 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 01/24/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some concentrator filter had a large amount of thick, white particle on it. Resident #39 said he did not know about the filter or if it got cleaned. During an interview on 01/24/24 at 10:57 a.m., LVN D said the Sunday night nurse was responsible for oxygen equipment dating, changing, and cleaning. He said oxygen equipment needed to be placed in a bag when not in use due to bacteria. He said dirty oxygen filters would cause the resident to not get amount of oxygen and placed them a risk for infections. During an interview on 01/24/24 at 12:16 p.m., RN M said she worked night shift. She said staff who took the oxygen equipment off the resident was responsible for placing it in bag. She said she did not know what the oxygen concentrator filter was and did not clean it. She said she did not know night nurses were responsible for cleaning them. She said she knew oxygen equipment was changed weekly on night shift and prn. She said not placing a nebulizer or CPAP mask in bags risked cross contamination. During an interview on 01/24/24 at 12:41 p.m., the ADON said CPAP and neb mask should be stored in a clear bag. She said nurses were responsible for placing equipment in bags when not in use. She said nurses were told upon hire to clean the oxygen concentrator filter with Sunday night tubing changes. She said not bagging equipment and not cleaning filters placed residents at risk for infections. She said she did audits on Mondays to ensure oxygen equipment was changed, cleaned, and stored correctly. She said she did not see Resident #39's dirty filter on Monday (01/22/24). During an interview on 01/24/24 at 1:06 p.m., the DON said nurses were responsible for oxygen equipment storage and cleaning. She said masks not in use should be stored in a plastic bag. She said she and the ADON were responsible for ensuring it was being done. She said they spot checked compliance but there was no routine or schedule. She said improper storage of equipment could get residents sick and expose them to bacteria. She said nurses were responsible for the oxygen concentrator filter but there was no physician order placed on the eMAR. She said nurses were told upon hire to clean the filters. She said filters were spot checked also. She said a dirty filter placed residents at risk for upper respiratory infection and poor oxygen movement. During an interview on 01/24/24 at 1:32 p.m., the ADM said direct care staff was responsible for oxygen equipment storage and filter cleaning. He said improper storage and dirty filters had the potential for increase of infection. He said he was not aware of the nursing staff process to ensure storage and cleaning of filters happened. He said these things should be checked during angel rounds. Review of a facility Oxygen Equipment policy revised on 05/2007 indicated, .It is the policy of this facility to maintain all oxygen therapy equipment in a clean and sanitary manner and to use disposable pre-filled humidifiers, tubing, masks and cannulas for residents receiving oxygen. This equipment is to be discarded after use. The facility will maintain clean tanks, connectors, and concentrators 2. Nebulizer equipment procedures A. Nebulizer equipment generates aerosols small enough to be readily deposited in the lungs. Careful technique is required to prevent infecting the resident .C. After each treatment, take the nebulizer apart and discard all unused medication. Rinse all parts thoroughly with warm water and air dry D. Daily dismantle entire breathing assembly including all hoses, wash with warm soapy water, rinse well and ensure parts are dry, including inside of hoses F. Store, clean, and dry until next use . oxygen concentrator filters will be cleaned with water and detergent every week .mask or cannula is temporarily not being used, it will be covered loosely to prevent contamination from airborne microorganisms . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 21 of 35 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 01/24/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 5 or 20 residents (Resident #16, Resident #22, Resident #33, Resident #39, and Resident #56) reviewed for respiratory care. Residents Affected - Some 1. The facility failed to properly store a nebulizer mask while not in use for Resident #56. 2. The facility failed to ensure Resident #16 and Resident #33 CPAP mask (a hose connected to a mask or nosepiece to deliver constant and steady air pressure to help you breathe while you sleep) was stored in a bag after use. 3. The facility failed to ensure Resident #22's nebulizer mask (provide vaporized medicine into the airway) was stored in a bag after use. 4. The facility failed to ensure Resident # 39's filter (the air passes through a series of filters that remove impurities, ensuring that the oxygen delivered to the patient is of high quality) in the oxygen concentrator (take air from your surroundings, extract oxygen and filter it into purified oxygen for you to breathe) was free of white, fuzzy particles. These failures could place residents at risk for of respiratory infections. Findings included: 1. Record review of an undated face sheet revealed Resident #56 was a [AGE] year-old, male, and admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing-related problems), need for assistance with personal care, and generalized anxiety disorder (worrying constantly and can't control the worrying). Record review of a quarterly MDS dated [DATE] revealed Resident #56 had a BIMS of 11, which indicated moderate cognitive impairment. Shows that Resident #56 receives oxygen therapy. Shows that resident #56 requires supervision with ADLs. Shows that Resident # 56 has severely impaired vision. Record review of the Resident #56s order summary report dated 7/24/23 revealed an order for Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) and Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML. Record review of Resident #56's care plan dated 1/22/24 revealed a problem initiated on 7/20/23, Resident # 56 has Respiratory Failure, Chronic Obstructive Pulmonary Disease. Give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness. During an observation on 01/22/24 at 9:39 a.m., Resident #56 was in his room asleep. It was observed that his nebulizer was laying on his bedside table not in use. There was no bag to store the nebulizer in. During an observation on 01/24/24 at 9:20 a.m., Resident #56 was not in his room and his nebulizer was laying on the edge of his bed not in a bag. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 22 of 35 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 01/24/2024 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 0695 During an observation on 01/22/24 at 10:20 a.m., Resident #56 started a breathing treatment with LVN D. Level of Harm - Minimal harm or potential for actual harm During an interview on 01/24/24 at 10:44 a.m., CNA E said she was trained to place all oxygen and nebulizer equipment into a bag when it was not in use. She said equipment was supposed to be cleaned but she was unsure how often oxygen and nebulizer equipment should be cleaned. She said if she saw a nebulizer laying on the floor or stored improperly it would need to be cleaned before it could be used again . She said residents could be placed at risk of infections if they were using nebulizers or oxygen equipment that was not stored properly. Residents Affected - Some During an interview and observation on 01/24/24 beginning at 11:03 a.m., Resident #56 said that his oxygen equipment was never in a bag. He said he doesn't know if staff changes the tubing. He said that he was blind so he wouldn't be able to see if the equipment was cleaned or changed out. He said he always wears his nasal cannula, and it only comes off if he transfers, showers, or the tubing was being changed out. He said he didn't know if his nebulizer should be stored in a bag and that no one has ever told him to store his nebulizer in a bag. He said he lays it where he can when he was not using it. The nebulizer was observed with medication in the reservoir and laying in resident's drawer. During an interview on 01/24/24 at 11:38 a.m., LVN D He stated nebulizers while not in use should be stored in a clean plastic bag near the bed. He said the reason was to help keep the nebulizer clean and prevent infections. He said everywhere he has ever worked the policy says to store nebulizer equipment in a bag. During an interview on 01/24/24 at 11:43 a.m., the DON said nebulizer equipment should be stored in a plastic bag while not in use. She said the purpose behind storing nebulizer equipment in this manner was to prevent infections that could be acquired through the use of dirty equipment. She said it is the responsibility of all staff to ensure that this practice is followed. During an interview on 01/24/24 at 11:48 a.m., the Administrator said that a nebulizer should be stored in a plastic bag while not in use. He said that residents could be exposed to infections should the nebulizer be stored inappropriately. He said that it would be improper to store a nebulizer in a drawer without a bag. He said all staff are responsible to ensure this policy is followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 23 of 35 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 01/24/2024 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (is a medication used: In excessive doses (including duplicate therapy); or For excessive duration; or Without adequate monitoring; or Without adequate indication for its use; or In the presence of adverse consequences which indicate the dose should be reduced or discontinued) for 2 of 5 residents (Resident #16 and Resident #33) reviewed for unnecessary medications in that: Residents Affected - Some The facility failed to ensure Resident #16 had behavior monitoring (is an on-going process to evaluate a person's distressed behaviors, including: o Physically aggressive behaviors - hitting, kicking, pushing, pinching o Verbally aggressive behaviors - screaming, cursing, insults o Sexually aggressive behaviors - sexual comments, inappropriate touching o Wandering o Taking, touching, or rummaging through another person's belongings) for his prescribed anticonvulsant medication (are prescription medications that help treat and prevent seizures). The facility failed to ensure Resident #16 had side effect (also known as adverse reactions, are unwanted undesirable effects that are possibly related to a drug) and effectiveness (the extent to which a drug achieves its intended effect in the usual clinical setting) monitoring for his prescribed anticonvulsant medication. The facility failed to ensure Resident #33 had behavior monitoring for his prescribed anticonvulsant medications. The facility failed to ensure Resident #33 had side effect and effectiveness monitoring for his prescribed anticonvulsant medications. These failures could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications. Findings included: 1. Record review of Resident #16's face sheet printed 01/22/24 indicated Resident #16 was an [AGE] year-old male and admitted on [DATE] and 11/08/23 with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following nontraumatic intracerebral hemorrhage (spontaneous bleeding into the brain tissue) affecting left non-dominant side, and encephalopathy (is a term that refers to brain disease, damage, or malfunction). Record review of Resident #16's quarterly MDS assessment dated [DATE] indicated Resident #16 was usually understood and usually had the ability to understand others. The MDS indicated Resident #16 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 24 of 35 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 01/24/2024 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 0757 Level of Harm - Minimal harm or potential for actual harm had unclear speech and impaired vision. The MDS indicated Resident #16 had a BIMS score of 07 which indicated severe cognitive impairment. The MDS indicated Resident #16 had functional limitation in range of motion on one side of the upper and lower extremities. The MDS indicated Resident #16 was dependent for toileting hygiene, shower/bath self, personal hygiene, and chair/bed-to-chair transfer. The MDS indicated Resident #16 had an active diagnosis of seizure disorder or epilepsy. Residents Affected - Some Record review of Resident #16's care plan dated 08/11/23 indicated Resident #16 had a seizure disorder. Interventions included assess asap if seizure activity occurs, give seizure medication as ordered by doctor, monitor/document side effects and effectiveness, and seizure documentation. Record review of Resident #16's order summary dated 01/22/24 indicated Phenytoin (an anti-epileptic drug, also called an anticonvulsant; works by slowing down impulses in the brain that cause seizures) Oral Suspension 125mg/5ml, give 16 ml by mouth one time a day for anticonvulsant, start date 11/08/23. The order summary did not reflect behavioral or side effect monitoring or effectiveness of medication. Record review of Resident #16's MAR dated 01/01/24-01/31/24 indicated Phenytoin Oral Suspension 125mg/5ml, give 16 ml by mouth one time a day for anticonvulsant, start date 11/08/23. Review of the MAR did not reflect behavioral or side effect monitoring or effectiveness of medication. 2. Record review of Resident #33's face sheet printed 01/22/24 indicated Resident #33 was an [AGE] year-old male and admitted on [DATE] and 05/28/23 with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following subarachnoid hemorrhage affecting left non-dominant side, seizures (is a sudden, uncontrolled burst of electrical activity in the brain), anxiety (is a feeling of fear, dread, and uneasiness), post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), and localization-related symptomatic epilepsy and epileptic syndromes with complex partial seizures (epilepsy that follows an injury to the brain known). Record review of Resident #33's annual MDS assessment dated [DATE] indicated Resident #33 was usually understood and usually had the ability to understand others. The MDS indicated Resident #33 had minimal difficulty hearing with no hearing aid, adequate vision, and clear speech. The MDS did not indicated Resident #33's BIMS score. The MDS indicated Resident #33 required substantial/maximal assistance for toileting, oral, personal hygiene, shower/bathe self, chair/bed-to-chair transfer, toilet transfer, lying to sitting on side of bed, and sit to stand. The MDS indicated Resident #16 received an antianxiety medication during the last 7 days of the assessment period. Record review of Resident #33's care plan dated 11/08/22 indicated Resident #33 was at risk for re-traumatization related to history of trauma post-traumatic stress disorder. Interventions included document behaviors and resident response to interventions, administer medications as ordered, monitor/document for side effects and effectiveness, and observe for side effects and adverse reactions of psychoactive medication. Record review of Resident #33's care plan dated 04/21/23 indicated Resident #33 had a seizure disorder. Interventions included assess asap if seizure activity occurs, give seizure medication as ordered by doctor, monitor/document side effects and effectiveness, and seizure documentation. Record review of Resident #33's order summary dated 01/22/24 indicated: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 25 of 35 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 01/24/2024 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some *Gabapentin (anticonvulsant; is a medicine used to treat partial seizures, nerve pain from shingles and restless leg syndrome) Capsule 100 MG, give 1 capsule by mouth three times a day for neuropathy, start date 01/04/23. *Levetiracetam (is used with other medications to treat seizures (epilepsy). It belongs to a class of drugs known as anticonvulsants) Oral tablet 500 MG, give 2 tablets by mouth two times a day related to other seizures, start date 01/11/23. Record review of Resident #33's MAR dated 01/01/24-01/31/23 indicated: *Gabapentin Capsule 100 MG, give 1 capsule by mouth three times a day for neuropathy, start date 01/04/23. *Levetiracetam Oral tablet 500 MG, give 2 tablets by mouth two times a day related to other seizures, start date 01/11/23. During an interview on 01/24/24 at 10:57 a.m., LVN D said resident prescribed antianxiety and anticonvulsant medication should have behavior and side effects monitoring. He said it should be charted on the MAR. He said he thought the behavior and side effects monitoring was an auto generated order when a medication was ordered. He said if it was not auto generated then the nurse who entered the medication should order the monitoring. He said it was important to have behavior and side effect monitoring to watch for specific medication side effects and monitor behaviors. During an interview on 01/24/24 at 12:16 p.m., RN M said psychotropic medications required monitoring for behaviors and side effects. She said the nurse who got the medication order should put in the monitoring orders also. She said not doing monitoring for psychotropic medications risked not knowing if the medication was working and if the resident was experiencing side effects. During an interview on 01/24/24 at 12:41 p.m., the ADON said antianxiety, and anticonvulsant should have behavior and side effect monitoring. She said the nurse who got the medication order should put in the monitoring orders in. She said nursing management did audit to ensure psychotropic medication had monitoring orders. She said it was important to have monitoring to make sure the medication was effective. During an interview on 01/24/24 at 1:06 p.m., the DON said all psychotropic medication are supposed to have behavior and side effect monitoring. She said the facility had standing orders for behavior and side effect monitoring. She said the nurse who got the medication order should put in the monitoring orders in. She said her and ADON spot checked for compliance but there was no schedule. She said monitoring was important for medications to ensure it was needed, working effectively, and no side effects were experienced. During an interview on 01/24/24 at 1:32 p.m., the ADM said he expected nursing staff to monitor behavior and side effects of psychotropic medications. He said nursing management was responsible to ensure this happened. Record review of a facility's Psychotropic Medications policy and procedure revised 12/23 indicated .the facility will ensure that .residents who use psychotropic drugs .and behavioral interventions .psychotropic medications as any drug that affect brain activities associated with mental processes and behavior .other medication are subjected to the psychotropic medication requirement if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 26 of 35 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 01/24/2024 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 0757 Level of Harm - Minimal harm or potential for actual harm documented use appears to be a substitution for another psychotropic medication rather than for the approved for original indication .the LN shall review the classification of the drug .its indication .behavioral monitors and related adverse side effects .the facility's interdisciplinary team will review to ensure .monitoring for adverse consequences and effectiveness of medications are in place . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 27 of 35 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 01/24/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have adequate monitoring in place for side effects associated with the use of psychotropic medications and documented in the clinical record for 1 of 5 residents reviewed for unnecessary psychotropic drugs (Resident #33). The facility failed to ensure Resident #33 had behavior monitoring for his prescribed anti-anxiety (treats anxiety disorders). The facility failed to ensure Resident #33 had side effect and effectiveness monitoring for his prescribed anti-anxiety. These failures could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications. Findings included: 1. Record review of Resident #33's face sheet printed 01/22/24 indicated Resident #33 was an [AGE] year-old male and admitted on [DATE] and 05/28/23 with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following subarachnoid hemorrhage affecting left non-dominant side, seizures (is a sudden, uncontrolled burst of electrical activity in the brain), anxiety (is a feeling of fear, dread, and uneasiness), post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), and localization-related symptomatic epilepsy and epileptic syndromes with complex partial seizures (epilepsy that follows an injury to the brain known). Record review of Resident #33's annual MDS assessment dated [DATE] indicated Resident #33 was usually understood and usually had the ability to understand others. The MDS indicated Resident #33 had minimal difficulty hearing with no hearing aid, adequate vision, and clear speech. The MDS did not indicated Resident #33's BIMS score. The MDS indicated Resident #33 required substantial/maximal assistance for toileting, oral, personal hygiene, shower/bathe self, chair/bed-to-chair transfer, toilet transfer, lying to sitting on side of bed, and sit to stand. The MDS indicated Resident #16 received an antianxiety medication during the last 7 days of the assessment period. Record review of Resident #33's care plan dated 11/08/22 indicated Resident #33 was at risk for re-traumatization related to history of trauma post-traumatic stress disorder. Interventions included document behaviors and resident response to interventions, administer medications as ordered, monitor/document for side effects and effectiveness, and observe for side effects and adverse reactions of psychoactive medication. Record review of Resident #33's care plan dated 08/15/23 indicated Resident #33 was prescribed anti-anxiety medication. Intervention included give anti-anxiety medications ordered by physician, monitor/document side effects and effectiveness. Record review of Resident #33's order summary dated 01/22/24 indicated: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 28 of 35 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 01/24/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few *Zoloft (antidepressant; is used to treat certain mental/mood disorders (such as depression, panic attacks, obsessive compulsive disorder, post-traumatic stress disorder, social anxiety disorder).) Oral Tablet 50 MG, give 1 tablet by mouth one time a day for depression related to anxiety disorder, start date 12/09/23. *Ativan (is used to treat anxiety disorders) Oral Tablet 1 MG (Lorazepam), give 1 tablet by mouth two times a day for seizures related to anxiety disorder, start date 03/29/23. Review of the order summary did not reflect behavioral or side effect monitoring or effectiveness of medications. Record review of Resident #33's MAR dated 01/01/24-01/31/23 indicated: *Zoloft Oral Tablet 50 MG, give 1 tablet by mouth one time a day for depression related to anxiety disorder, start date 12/09/23. *Ativan Oral Tablet 1 MG (Lorazepam), give 1 tablet by mouth two times a day for seizures related to anxiety disorder, start date 03/29/23. Review of the MAR did not reflect behavioral or side effect monitoring or effectiveness of medications. During an interview on 01/24/24 at 10:57 a.m., LVN D said resident prescribed antianxiety and anticonvulsant medication should have behavior and side effects monitoring. He said it should be charted on the MAR. He said he thought the behavior and side effects monitoring was an auto generated order when a medication was ordered. He said if it was not auto generated then the nurse who entered the medication should order the monitoring. He said it was important to have behavior and side effect monitoring to watch for specific medication side effects and monitor behaviors. During an interview on 01/24/24 at 12:16 p.m., RN M said psychotropic medications required monitoring for behaviors and side effects. She said the nurse who got the medication order should put in the monitoring orders also. She said not doing monitoring for psychotropic medications risked not knowing if the medication was working and if the resident was experiencing side effects. During an interview on 01/24/24 at 12:41 p.m., the ADON said antianxiety, and anticonvulsant should have behavior and side effect monitoring. She said the nurse who got the medication order should put in the monitoring orders in. She said nursing management did audit to ensure psychotropic medication had monitoring orders. She said it was important to have monitoring to make sure the medication was effective. During an interview on 01/24/24 at 1:06 p.m., the DON said all psychotropic medication are supposed to have behavior and side effect monitoring. She said the facility had standing orders for behavior and side effect monitoring. She said the nurse who got the medication order should put in the monitoring orders in. She said her and ADON spot checked for compliance but there was no schedule. She said monitoring was important for medications to ensure it was needed, working effectively, and no side effects were experienced. During an interview on 01/24/24 at 1:32 p.m., the ADM said he expected nursing staff to monitor behavior and side effects of psychotropic medications. He said nursing management was responsible to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 29 of 35 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 01/24/2024 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 0758 ensure this happened. Level of Harm - Minimal harm or potential for actual harm Record review of a facility's Psychotropic Medications policy and procedure revised 12/23 indicated .the facility will ensure that .residents who use psychotropic drugs .and behavioral interventions .psychotropic medications as any drug that affect brain activities associated with mental processes and behavior .other medication are subjected to the psychotropic medication requirement if documented use appears to be a substitution for another psychotropic medication rather than for the approved for original indication .the LN shall review the classification of the drug .its indication .behavioral monitors and related adverse side effects .the facility's interdisciplinary team will review to ensure .monitoring for adverse consequences and effectiveness of medications are in place . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 30 of 35 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 01/24/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.Record review of the undated face sheet indicated Resident #45, a [AGE] year old male admitted [DATE]. Record review of the consolidated physician's orders dated 1/22/24 indicated Resident #45 had diagnoses including: chronic systolic congestive heart failure (the heart cannot pump enough blood to provide the body with the blood and oxygen it needs), chronic pulmonary embolism (blockage of an artery in the lungs), constipation (passing less than three bowel movements a week), and Chronic Obstructive Pulmonary Disease (progressive lung disease causing airflow limitation), Record review of the quarterly MDS dated [DATE] indicated Resident #45 had minimal difficulty hearing, clear speech, was understood by others, and understood others. The BIMS interview was dashed meaning there were no scores on his cognitive abilities. Record review of the undated care plan indicated Resident #45 was on pain medication, diuretic and anticoagulant therapy. The care plan indicated he had congestive heart failure and constipation. The care plan indicated he was at risk for a communication problem related to a hearing deficit. During an observation and interview on 1/22/24 beginning at 9:39 AM, Resident #45 was lying in bed. There was a cup of medications in his room and a small cup of white liquid. He said they were his medications and he had not taken them yet. During an interview on 1/22/24 at 9:46 AM, LVN A said she left Milk of Magnesia (MOM) and a cup of pills in Resident #45's room. She said he was just about to take them when she left because was sitting up in his bed. She walked to his room and took the medications out of his room. She said she would give them to him later. She said nurses were supposed to stay with the residents until they took/swallowed all their medications. During an interview and record review on 1/22/24 at 10:52 AM, LVN A provided a list of medications that were left in Resident #45's room. The list she provided indicated: Hydrocodone 7.5-325 mg, 1 tab (pain medication) Colace 100 mg, 1 tab (stool softener) Eliquis 2.5 mg, 1 tab (blood thinner) Famotidine 20 mg, 1 tab (acid reducer for stomach) Furosemide 40 mg, 1 tab (diuretic, a water pill) Guaifenesin 400 mg, 1 tab (expectorant, cough medicine) Movantik, 25 mg, 1 tab (constipation) Lyrica 75 mg, 1 tab (nerve pain medication) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 31 of 35 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 01/24/2024 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 0761 Milk of Magnesia, 30 ml (constipation) Level of Harm - Minimal harm or potential for actual harm During an interview on 1/23/24 at 12:14 PM, LVN A said she normally stayed with residents until they had taken all their medications. She said she said she should have stayed with Resident #45 until he had taken all his medications. She said she had not done that before. She said it was possible another resident could have gotten the medications, but she did not believe that would have happened. Residents Affected - Some During an interview on 1/23/24 at 1:07 PM, RN B said she would never leave medication, pills, liquid, or capsules in a resident's room. She said part of being a nurse was making sure residents took their medication. She said if she did not watch them take the medication they could spill it, set it down, not take it, or anyone could get it. She said medication was not administered until it was swallowed. During an interview on 1/23/24 at 2:18 PM, LVN C said he always made sure his residents had taken all their medications before he left their room. He said it was common sense for a nurse to make sure the resident took all their medications in front of the nurse. He said many things could go wrong if a nurse did not do that. He said the resident could save and stockpile the medication or someone else could get and take the medication. During an interview on 1/24/24 at 10:48 AM, the ADON said medications should not ever be left at bedside. She said the nurse should have watched Resident #45 take all the medication before she left the room. She said LVN A should have known better. She said Resident #45 could have stock-piled the medication, given it to someone, or anyone could have gotten it. She said there was potential for harm if another resident had gotten the medications. During an interview on 1/24/24 at 10:56 AM, the DON said medications should never be left in a resident's room because they might not take the medications, or someone else could take them. She said the nurse could not verify the resident received their ordered medications if the nurse did not see them swallow the medications. She said the potential for harm was that anyone could get the medication, or the resident would not receive the dose of something they needed. She said the nurse was responsible for making sure the medication was not left at bedside. During an interview on 1/24/24 at 11:03 AM, the ADM said nurses should never leave medications at the bedside. He said nurses should watch the resident take all the medications before leaving the room. He said the resident could choke on the medications, they could be taken at the wrong time, or someone else could get the medications. He said if another resident got the medications that were left in the room that could result in harm. The ADM said the person responsible for making sure medications were not left at the bedside was the nurse giving the medications. The DON provided an in-service done 1/22/24 that indicated: You must give every medication that is on the EMAR. Do not pre-pull medications. All medication is to be given and taken within the nurse's view. It is not to be left at bedside. If a resident requests a pain medication you are to go assess resident's pain and administer PRN med at that time. Do not wait until an hour or longer to give a pain medication. This in-service was signed by several staff including LVN A. The Regional Nurse provided a policy, Nursing Clinical, Care and Treatment, Medication Access and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 32 of 35 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 01/24/2024 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 0761 Storage dated 05/2007 that indicated: Level of Harm - Minimal harm or potential for actual harm It is the policy of this facility to store all drugs and biologicals in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, or staff members lawfully authorized to administer medications. Residents Affected - Some During an interview on 1/23/24 at 9:02 AM, the ADM said the policy regarding medication storage was the only policy they had regarding leaving medications at bedside. Based on observations, interviews, and record review, the facility failed to provide separately locked, permanently affixed compartments for storage of controlled drugs for 1 of 1 medication rooms reviewed for storage of medication.The facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #45) of 16 residents reviewed for pharmacy services. 1.The facility failed to ensure the narcotic box was permanently affixed inside the refrigerator in Medication room [ROOM NUMBER]. 2. The facility failed to ensure accurate medication administration and securely store Resident #45's Hydrocodone, Colace, Eliquis, Famotidine, Furosemide, Guaifenesin, Movantik, Lyrica, and Milk of Magnesia that were at the resident's bedside. This failure could place residents that take narcotics that required refrigeration at risk of misappropriation of drugs. Findings included: During observation and interview on 1/23/2024 at 2:37 PM, RN S went in medication room [ROOM NUMBER] and a black plastic lockbox was sitting on top of a 2- door mini-refrigerator. RN S unlocked and opened the narcotic box revealing two medications: Lorazepam and Dronabinol. Lorazepam 2mg/ml was labeled to Resident # 54 and Dronabinol 5 mg was labeled to Resident #12. RN S said the narcotic box was supposed to be affixed inside the refrigerator. RN S said someone could just walk out with the narcotic box if not secure inside refrigerator. During observation and interview on 1/23/2024 at 2:46 PM, there was a black box with a lock on it sitting on top of the refriderator in Medication room [ROOM NUMBER]. The box was not secured to the refriderator. The DON said the black box was the narcotic box and someone could walk out with unsecured narcotic box. During record review of face sheet dated 1/24/2024, indicated Resident #12 was an 82- year- old male that was admitted on [DATE]. During Record review of Comprehensive MDS dated [DATE], indicated Resident #12 had clear speech, was understood by others, and usually understood others. He had a BIMS score of 12 indicating mild cognitive impairment. A record review of Resident #12's MAR Resident had received Marinol (Dronabinol) 5 mg 1 capsule at bedtime for decreased appetite for 7 of 7 days of the lookback period. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 33 of 35 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 01/24/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm A record review of the MDS dated [DATE], indicated Resident # 12 had diagnosis that included: Atrial Fibrillation (An irregular and often very rapid heart rhythm), Coronary artery Disease (damage or disease in the hearts major blood vessels),Malnutrition (lack of proper nutrition), Septicemia (blood poisoning caused by bacteria or their toxins), urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder or urethra) and arthritis (inflammation of one or more joints, causing pain and stiffness). Residents Affected - Some During record review of face sheet dated 1/24/2024, indicated Resident # 54 was a [AGE] year-old male that was admitted on [DATE]. During record review of MDS dated [DATE], indicated Resident # 54 clear speech was usually understood by others and usually understood others. He had a BIMS score of 9 indicating moderate cognitive impairment. A record review of Resident #54's MAR dated January 2024 indicated Resident #54 recieved Lorazepam 2mg/ml at bedtime for the last 14 days with the first day being 1/9/24 and the last day was 1/24/24. During record review of Quarterly MDS dated [DATE], indicated Resident # 54 had diagnosis that include: (COPD) Chronic Obstructive Pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), muscle weakness, Tinea Corporis (highly contagious, fungal infection of the skin or scalp), Hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone) and primary osteoarthritis of right shoulder (a type of arthritis that occurs when flexible tissue at the ends of bones wear down). During observation on 1/24/2024 at 8:42 AM, there was a black box sitting on top of the refrigerator unsecured and not affixed to anything. During observation and interview on 1/24/2024 beginning at 8:50 AM, the ADM said the narcotic box was now chained up and secured in the refrigerator. The ADM said he was unsure why the narcotic lockbox was not secured inside the refrigerator. During interview on 1/24/2024 at 10:23 AM, Maintenance Supervisor L said the DON was responsible for securing the lock box. Maintenance Supervisor L said anyone with a key to the med room could leave with the unsecured box since it was not secured. During interview on 1/24/2024 at 12:45 PM, RN H said the nurses were responsible for ensuring the lock box was secured. RN H said she had not noticed the lockbox being unsecured and said there was a new refrigerator in there now. RN H said someone could remove the lockbox which would result in a drug diversion if it was not secured. During interview on 1/24/2024 at 1:10 PM, LVN G said every nurse who goes to the medication storage room was responsible to ensure the lockbox was secured. LVN G said a drug diversion could occur if the lockbox was not secured to the refrigerator. During interview on 1/24/2024 at 1:13 PM, the ADON said the previous lockbox was secured in refrigerator. The ADON said the medications could be stored at improper temperatures and could be misplaced. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 34 of 35 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 01/24/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During interview on 1/24/2024 at 1:42 PM, the DON said the lockbox was previously secured in refrigerator. The DON said someone could steal narcotics or take the narcotics if it was not secured. During interview on 1/24/2024 at 2:02 PM, the ADM said the nurses were responsible for ensuring the narcotic lockbox was secured. The ADM said the Maintenance supervisor was responsible for securing the lockbox in the refrigerator. The ADM said the lockbox could grow legs and walk off if not secured in refrigerator. A policy titled Clinical Nursing revised date 5/2001 provided by the DON revealed It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures revealed Scheduled III and IV controlled medications are stored separately from other medications in a locked drawer or compartment designated for that purpose . Scheduled II medications are stored in a separate area under double lock. Medications requiring storage at room temperature are kept at temperatures ranging from 15 degrees Celsius (59 degrees Fahrenheit) to 30 degrees Celsius (86 degrees Fahrenheit). Medications requiring refrigeration or temperatures between 2 degrees Celsius (36 degrees Fahrenheit) and 8 degrees Celsius (46 degrees Fahrenheit) are kept in refrigerator with a thermometer to allow temperature monitoring. 11. Refrigerated medications are kept in closed and labeled containers, with internal and external medications separated, and separate from fruit juices . A policy titled Controlled Medications- Storage and Reconciliation revised on 12/2023 revealed It is the policy of this facility to safeguard access and storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse using separately locked, permanently affixed compartments, with the exception that controlled medications and those medications are subject to abuse may be stored with non-controlled medications as part of a single unit package medication distribution system, if the supply of the medication (s) is minimal and a shortage is readily detectable . Procedure revealed Medications listed in the Schedule II, III, IV and V are stored under double-lock in a locked cabinet or safe designated for that purpose, separate from all other medications . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 35 of 35