Health inspection·February 22, 2024

F 0563 Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility did not ensure the right to receive visitors of his or her choosing at the time of his or her choosing for 1 of 1 facility reviewed for resident rights. Residents Affected - Few The facility did not allow visitors between the hours of 10:00 p.m. to 8:00 a.m. except in the event of end of life. This failure could place residents at risk for emotional and psychological harm. Findings included: Record review of a nursing progress note dated 4/22/23 at 11:20 p.m. written by LVN A indicated, [Resident #1's family was] notified by this nurse [at 10:40 p.m. that visiting hours [had] ended, [the family] voiced understanding. [Resident #1's family exited the] facility at this time . Record review of an undated sticky note provided by the DON indicated the facility did not have a policy regarding visitation hours. The sticky note indicated visiting hours were 8:00 a.m. until 10:00 p.m. with exceptions made for end of life. During an interview on 2/21/24 at 2:10 pm, the DON said they told families visiting hours were from 8:00 a.m. to 10:00 p.m. because they did not want to disturb other residents. The DON said the door alarms would go off with people entering and exiting the building and the alarms were loud. The DON said residents needed to sleep. During an interview on 2/22/24 at 12:30 p.m., the Administrator said the facility did not have a policy regarding visiting hours. The Administrator said the facility did not enforce visiting hours. The Administrator said the facility made exceptions on a case-by-case basis. The Administrator said the residents needed to sleep. Record review of the facility's Visitation policy revised May 2007 indicated, It is the policy of this facility to: 1. Allow access to resident by family members and other appropriate parties to the extent that Resident Rights require. 2. Deny access to visitors when the resident requests or other specific factors are present .3. Families, friends, clergy, and volunteers are encouraged to visit with residents during visiting hours. 4. The facility established visiting hours are scheduled to meet the needs of most potential visitors. 5. Special provisions will be made by the Administrator and/or the Director of Nursing Services (unless prohibited by the resident's physician and so documented) to accommodate visitors when the resident make a request or when the resident is in critical Page 1 of 12 676048 676048 02/22/2024 Legend Oaks Healthcare and Rehabilitation Center - 1201 Fm 2685 Gladewater, TX 75647

F 0563 condition . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 676048 Page 2 of 12 676048 02/22/2024 Legend Oaks Healthcare and Rehabilitation Center - 1201 Fm 2685 Gladewater, TX 75647

F 0603 Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure residents had the right to be free from involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms for 1 of 4 (Resident #1) residents reviewed for involuntary seclusion. Residents Affected - Some The facility failed to follow their policy for residents refusing the test for COVID-19 resulting in Resident #1 being placed in isolation from 7/18/23 through 8/18/23 (32 days), 10/3/23 through 10/16/23 (13 days), and 11/6/23 through 11/11/23 (6 days). This failure could place residents at risk for increased depression and emotional and psychological harm. Findings included: Record review of the face sheet dated 2/22/24 indicated Resident #1 admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), hemiparesis (partial weakness to one side) and hemiplegia (paralysis to one side) following cerebral infarction affecting the left side, dementia, muscle weakness, and lack of coordination. Record review of the MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS of 09 and was moderately cognitively impaired. The MDS indicated Resident #1 used a wheelchair for mobility. Record review of the care plan last updated 12/1/23 indicated Resident #1's family requested for him not to be tested for COVID-19 starting 7/27/23. The care plan indicated interventions were in place including patient to stay in room while during COVID outbreak starting 12/1/23. Record review of a nursing progress note dated 7/27/23 at 7:42 a.m. written by the DON indicated, Family continues to refuse to have [Resident #1] tested for COVID despite facility outbreak. [Resident #1's family] educated on [the] risks of not identifying [a] COVID infection. [Resident #1's family] continued to refuse. Will continue to encourage [the family] to consider testing should symptoms arise. Record review of a nursing progress note dated 7/27/23 at 10:42 a.m. written by the DON indicated, [The] Ombudsman [was] notified of [the] family's refusal [for Resident #1] to participate in [COVID] testing. [The] Ombudsman stated [Resident #1] should be treated like a positive [COVID] case and [Resident #1 needed] to remain in isolation until [the COVID] outbreak was over or [the] family agreed to outbreak testing [for Resident #1]. Record review of a nursing progress note dated 8/15/23 at 11:13 a.m. written by the DON indicated, [Resident #1's family] in facility at this time requesting [Resident #1] be allowed out of room. [Resident #1's family was educated] on COVID outbreak in facility and .due to family request for resident to not be tested for COVID, resident would be treated as if they were COVID positive for the duration of the outbreak as previously agreed upon. [Resident #1's family was] upset with [the] isolation of [Resident #1] and requesting exception be made. Education [was] provided to [Resident #1's family] regarding CMS guidelines and need for maintaining safety of all residents within facility. 676048 Page 3 of 12 676048 02/22/2024 Legend Oaks Healthcare and Rehabilitation Center - 1201 Fm 2685 Gladewater, TX 75647

F 0603 Level of Harm - Actual harm Residents Affected - Some Educated [Resident #1's family he] would be allowed out of room once outbreak period was over or [if Resident #1] had a negative COVID test. [Resident #1's family was] visibly upset at this time and left DON's office. Record review of a nursing progress note date 10/3/23 at 11:21 a.m. written by RN B indicated, [Due to a] Covid outbreak and family's refusal to allow testing, [Resident #1] was to be treated as Covid positive until we are out outbreak. Family has been notified and wife verbally complied. During an interview on 2/13/24 at 11:47 a.m. the Ombudsman said she felt there was a miscommunication with the facility regarding the COVID outbreak. The Ombudsman said Resident #1's family refused to for him to be COVID tested. The Ombudsman said she had advised the facility he had the right to refuse but they could put him in quarantine for 10 days to watch for signs and symptoms. The Ombudsman said the facility restarted Resident #1's quarantine time every time during the initial outbreak that another resident tested positive for COVID. The Ombudsman said the facility ended up keeping Resident #1 in quarantine for 7 weeks. During an interview on 2/14/24 at 10:12 am LVN C said he was not familiar with Resident #1. LVN C said Resident #1 was not on his hall during his admission to the facility. LVN C said if a resident tested positive for COVID they would be placed in isolation with contact precautions in place. LVN C said if a resident refused to be COVID tested they would be placed in isolation for approximately 5-7 days. LVN C said if a resident was non-compliant with isolation, they would encourage them to keep distant from other residents and wear a mask. LVN C said a resident could not be forced to stay in their room. During an interview on 2/14/24 at 10:17 a.m. RN B said she was familiar with Resident #1. RN B said the family did not want him tested for COVID. RN B said when the facility had a COVID outbreak in the summer of 2023 Resident #1 was placed in isolation due to refusal to test for COVID. RN B said the outbreak lasted approximately 2 months. RN B said she did not remember the exact length of Resident #1's isolation, but it was quite a while. RN B said the Administrator had discussed the isolation with Resident #1's POA. RN B said Resident #1 was not allowed out of his room during his isolation. RN B said the family would sneak him out of his room and take him outside. RN B said the Administrator went outside each time the family took Resident #1 outside and told them they were not allowed to be out of the room and need to go back due to Resident #1 being in isolation. RN B said a resident that tested negative for COVID and was symptomatic would be placed on isolation for 7 days. RN B said she thought a resident who tested positive for COVID would be placed in isolation for 7-10 days. During an interview on 2/14/24 at 1:23 p.m. the family said they were not informed of Resident #1's isolation status during the COVID breakout during summer 2023. The family said the DON told them she had been told by the Ombudsman to isolate Resident #1 for the entire time of the COVID outbreak due to refusal of COVID testing. The family said the Ombudsman denied telling the DON that Resident #1 had to isolated during the entire COVID outbreak. During an interview on 2/15/24 at 9:33 a.m. the Infection Preventionist said she had been the infection preventionist at the facility for a couple years. The Infection Preventionist said she performed the COVID testing on residents. The Infection Preventionist said Resident #1 had been COVID tested in the past prior to a care plan meeting with the social worker where the family requested no COVID testing moving forward. The Infection Preventionist said if a resident tested positive for COVID they would be moved to a different room and placed in isolation for 10 days as long as symptoms were not worsening. The Infection Preventionist said if a resident had been exposed to COVID, was 676048 Page 4 of 12 676048 02/22/2024 Legend Oaks Healthcare and Rehabilitation Center - 1201 Fm 2685 Gladewater, TX 75647

F 0603 Level of Harm - Actual harm Residents Affected - Some symptomatic or asymptomatic, but tested negative for COVID they would not be placed in isolation they would only be monitored and tested as needed. The Infection Preventionist said they could not isolate someone who tested negative. The Infection Preventionist said if a resident refused to be tested for COVID during an outbreak they would be treated as if they were an unknown COVID positive and be required to be in isolation for the duration of the outbreak. The Infection Preventionist said if a resident was non-compliant with isolation staff would re-educate them, put a mask on the resident, and redirect them back to their room. The Infection Preventionist said she was on leave during the outbreak which started at the end of June 2023, but that Resident #1 should have been in isolation for the duration of the outbreak due to refusal to test for COVID. During an interview on 2/15/24 at 10:34 a.m. CNA D said if a resident tested positive for COVID they would be placed in isolation and staff would wear N95 masks while in the building. CNA D said the COVID positive resident would be in isolation for 10-12 days. CNA D said if a resident was exposed to COVID but tested negative for COVID they would not be moved or put in isolation. CNA D said Resident #1 was the only resident she was ever aware of refusing to be COVID tested. CNA D said Resident #1 was placed on isolation in the summer 2023 during a COVID outbreak for the duration of the outbreak. During an interview on 2/15/24 at 10:38 a.m. LVN E said she had worked at the facility for 12 years. LVN E said if a resident tested positive for COVID they would be placed in isolation, the facility would begin outbreak testing, and staff would wear N95 masks while in the facility. LVN E said a COVID positive resident would be in isolation for 10 days. LVN E said if a resident was exposed to COVID, was symptomatic, and tested negative for COVID they would be placed in isolation for 7-10 days or until they were no longer symptomatic. LVN E said if a resident refused to be COVID tested and were asymptomatic they would be put in isolation because the facility would not know if they were COVID positive. LVN E said a resident who refused to be COVID tested would be in isolation until they agreed to be tested. LVN E said if a resident was non-compliant with isolation staff would educate the resident, contain to illness, wound, etc., and perform/encourage frequent hand hygiene. During an interview on 2/15/24 at 12:58 pm the DON said if the facility had a COVID positive resident they would begin outbreak testing on days 1.3. and 5 and isolate the COVID positive resident for 10 days. The DON said in July 2023 the facility was considered in outbreak until they went 14 days without a COVID positive test. The DON said if a resident had been exposed to COVID, was symptomatic, and tested negative they would not be put in isolation. The DON said if a resident refused to test for COVID they would be put in isolation until the facility was out of outbreak. The DON said Resident #1 refused to be COVID tested and was placed in isolation for the duration of the outbreak that occurred in the summer of 2023. The DON said Resident #1 was asymptomatic during the isolation and outbreak. The DON said Resident #1 only interacted with other resident while in therapy, when eating in the dining room, and sometimes when brought to activities by his family, but for the most part was not around other residents a lot. The DON said if the facility had ended Resident #1's isolation after 10 days and they were still in outbreak he would have been re-exposed and required another 10-day isolation. The DON said Resident #1 was isolated during the facility's COVID outbreak in November 2023. During an interview on 2/20/24 at 1:06 p.m. Resident #1's family said on 8/16/23 they took Resident #1 outside and were yelled at by the DON to go back to the Resident #1's room. The family said Resident #1 started crying when the DON yelled at them . The family said during the October COVID isolation Resident #1 was isolated for 3 weeks after they had been told it would only be a 14-day isolation. They said Resident #1 was put in isolation again in November due to another COVID outbreak at the 676048 Page 5 of 12 676048 02/22/2024 Legend Oaks Healthcare and Rehabilitation Center - 1201 Fm 2685 Gladewater, TX 75647

F 0603 Level of Harm - Actual harm Residents Affected - Some facility and refusal to COVID test. The family said during one of his isolations they had taken Resident #1 outside to the front porch of the facility and away from other residents. The family said the Administrator came out and told them they could not be outside or out of the room. The family said she asked why as they were not near any other person. The family said they were wearing masks at the time. The family said the Administrator said something about Resident #1 shedding and it was blowing towards him, and he could get COVID from the shedding. The family said the Administrator continued to stand there looking at them and Resident #1 began to get upset so she reluctantly took Resident #1 back to his room. During an interview on 2/21/24 at 1:15 p.m. the DON said during his isolation Resident #1 was permitted to go outside. The DON said there were stipulations on him going outside. The DON said the stipulations included Resident #1 had to wear a mask when transporting through the facility and had to come back in or wear a mask if other residents were outside. The DON said there were only 2 sitting areas outside and she guessed they were only about 4 feet apart, but she had not measured it. Record review of the facility's Freedom from Abuse, Neglect, Exploitation policy revised 12/2023 indicated, It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. It is also the policy of this facility to recognize the resident right to personal privacy and confidentiality of their physical body personal care, and personal space or accommodations. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms .Involuntary seclusion is separation of a resident from other residents or from his/her room or confinement to his/her room (with or without roommates) against the resident's will, or the will of the resident's representative . Record review of the facility's COVID-19 Testing policy revised 10/2022 indicated, It is the policy of this facility to provide or obtain laboratory testing services for residents and staff to assist in the identification and management of COVID-19 infections and/or outbreaks. Testing will be performed according to current local/state health departments and Centers for Disease Control and Prevention guidelines .Resident declines: Resident or resident representatives my exercise their right to decline COVID-19 testing. A. If a resident has known exposure to COVID-19 or is symptomatic regardless of vaccination status and declines testing, the resident will be placed on transmission-based precautions (TBP) until criteria for discontinuation is met. B. If outbreak testing has been triggered and an asymptomatic resident refuses testing, the facility should be extremely vigilant, such as through additional monitoring, to ensure the resident maintains the appropriate distance from the other residents, wears a face covering, and practices effective hand hygiene until the procedures for outbreak testing have been completed . Record review of the facility's undated Transmission Based Precaution and Isolation policy indicated, It is the policy of [the facility] to implement infection control measures to prevent the spread of communicable disease and conditions. Int LTC, it is appropriate to individualize decisions regarding resident placement (shared or private), balancing infection risks with the need for more than one occupant in the room, the presence of risk factors that increase the likelihood of transmission, and the potential for adverse psychological impact on the infected or colonized resident. It is therefore appropriate to use the least restrictive approach possible that adequately protect the residents and others. Maintaining isolation longer than necessary may adversely affect psychosocial well-being . 676048 Page 6 of 12 676048 02/22/2024 Legend Oaks Healthcare and Rehabilitation Center - 1201 Fm 2685 Gladewater, TX 75647

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 (Resident #1 and Resident #2) residents reviewed for infection control. Residents Affected - Some 1. The facility failed to ensure they used the least restrictive isolation possible for Resident #1 when he was put in isolation from 7/18/23 through 8/18/23 (32 days), 10/3/23 through 10/16/23 (13 days ), and 11/6/23 through 11/11/23 (6 days) due to refusing to be COVID tested. 2. The facility failed to ensure CNA F did not use contaminated wipes and gloves when performing in continent care on Resident #2. These failures could place residents and staff at risk for decreased quality of life, infection from contaminated products, and could potentially affect all others in the building. Findings Included: 1. Record review of the face sheet dated 2/22/24 indicated Resident #1 admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), hemiparesis (partial weakness to one side) and hemiplegia (paralysis to one side) following cerebral infarction affecting the left side, dementia, muscle weakness, and lack of coordination. Record review of the MDS assessment dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS of 09 and was moderately cognitively impaired. The MDS indicated Resident #1 used a wheelchair for mobility. Record review of the care plan last updated 12/1/23 indicated Resident #1's family requested for him not to be tested for COVID-19 starting 7/27/23. The care plan indicated interventions were in place including patient to stay in room while during COVID outbreak starting 12/1/23. Record review of a nursing progress note dated 7/27/23 at 7:42 a.m. written by the DON indicated, Family continues to refuse to have [Resident #1] tested for COVID despite facility outbreak. [Resident #1's family] educated on [the] risks of not identifying [a] COVID infection. [Resident #1's family] continued to refuse. Will continue to encourage [the family] to consider testing should symptoms arise. Record review of a nursing progress note dated 7/27/23 at 10:42 a.m. written by the DON indicated, [The] Ombudsman [was] notified of [the] family's refusal [for Resident #1] to participate in [COVID] testing. [The] Ombudsman stated [Resident #1] should be treated like a positive [COVID] case and [Resident #1 needed] to remain in isolation until {the COVID] outbreak was over or [the] family agreed to outbreak testing [for Resident #1]. Record review of a nursing progress note dated 8/15/23 at 11:13 a.m. written by the DON indicated, [Resident #1's family] in facility at this time requesting [Resident #1] be allowed out of room. [Resident #1's family was educated] on COVID outbreak in facility and .due to family request for resident to not be tested for COVID, resident would be treated as if they were COVID positive for the 676048 Page 7 of 12 676048 02/22/2024 Legend Oaks Healthcare and Rehabilitation Center - 1201 Fm 2685 Gladewater, TX 75647

F 0880 Level of Harm - Minimal harm or potential for actual harm duration of the outbreak as previously agreed upon. [Resident #1's family was] upset with [the] isolation of [Resident #1] and requesting exception be made. Education [was] provided to [Resident #1's family] regarding CMS guidelines and need for maintaining safety of all residents within facility. Educated [Resident #1's family he] would be allowed out of room once outbreak period was over or [if Resident #1] had a negative COVID test. [Resident #1's family was] visibly upset at this time and left DON's office. Residents Affected - Some Record review of a nursing progress note date 10/3/23 at 11:21 a.m. written by RN B indicated, [Due to a] Covid outbreak and family's refusal to allow testing, [Resident #1] was to be treated as Covid positive until we are out outbreak. Family has been notified and wife verbally complied. During an interview on 2/13/24 at 11:47 a.m., the Ombudsman said she felt there was a miscommunication with the facility regarding the COVID outbreak. The Ombudsman said Resident #1's family refused for him to be COVID tested. The Ombudsman said she had advised the facility he had the right to refuse but they could put him in quarantine for 10 days to watch for signs and symptoms. The Ombudsman said the facility restarted Resident #1's quarantine time every time during the initial outbreak that another resident tested positive for COVID. The Ombudsman said the facility ended up keeping Resident #1 in quarantine for 7 weeks. During an interview on 2/14/24 at 10:12 am, LVN C said he was not familiar with Resident #1. LVN C said Resident #1 was not on his hall during his admission to the facility. LVN C said if a resident tested positive for COVID they would be placed in isolation with contact precautions in place. LVN C said if a resident refused to be COVID tested, they would be placed in isolation for approximately 5-7 days. LVN C said if a resident was non-compliant with isolation, they would encourage them to keep distant from other residents and wear a mask. LVN C said a resident could not be forced to stay in their room. During an interview on 2/14/24 at 10:17 a.m., RN B said she was familiar with Resident #1. RN B said the family did not want him tested for COVID. RN B said when the facility had a COVID outbreak in the summer of 2023, Resident #1 was placed in isolation due to refusal to test for COVID. RN B said the outbreak lasted approximately 2 months. RN B said she did not remember the exact length of Resident #1's isolation, but it was quite a while. RN B said the Administrator had discussed the isolation with Resident #1's POA. RN B said Resident #1 was not allowed out of his room during his isolation. RN B said the family would sneak him out of his room and take him outside. RN B said the Administrator went outside each time the family took Resident #1 outside and told them they were not allowed to be out of the room and need to go back due to Resident #1 being in isolation. RN B said a resident that tested negative for COVID and was symptomatic would be placed on isolation for 7 days. RN B said she thought a resident who tested positive for COVID would be placed in isolation for 7-10 days. During an interview on 2/14/24 at 1:23 p.m., the family said they were not informed of Resident #1's isolation status during the COVID breakout during summer 2023. The family said the DON told them she had been told by the Ombudsman to isolate Resident #1 for the entire time of the COVID outbreak due to refusal of COVID testing. The family said the Ombudsman denied telling the DON that Resident #1 had to isolated during the entire COVID outbreak. During an interview on 2/15/24 at 9:33 a.m., the Infection Preventionist said she had been the infection preventionist at the facility for a couple years. The Infection Preventionist said she performed the COVID testing on residents. The Infection Preventionist said Resident #1 had been COVID 676048 Page 8 of 12 676048 02/22/2024 Legend Oaks Healthcare and Rehabilitation Center - 1201 Fm 2685 Gladewater, TX 75647

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some tested in the past prior to a care plan meeting with the social worker where the family requested no COVID testing moving forward. The Infection Preventionist said if a resident tested positive for COVID, they would be moved to a different room and placed in isolation for10 days as long as symptoms were not worsening. The Infection Preventionist said if a resident had been exposed to COVID, was symptomatic or asymptomatic, but tested negative for COVID, they would not be placed in isolation, and they would only be monitored and tested as needed. The Infection Preventionist said they could not isolate someone who tested negative. The Infection Preventionist said if a resident refused to be tested for COVID during an outbreak, they would be treated as if they were an unknown COVID positive and be required to be in isolation for the duration of the outbreak. The Infection Preventionist said if a resident was non-compliant with isolation staff would re-educate them, put a mask on the resident, and redirect them back to their room. The Infection Preventionist said she was on leave during the outbreak which started at the end of June 2023, but that Resident #1 should have been in isolation for the duration of the outbreak due to refusal to test for COVID. During an interview on 2/15/24 at 10:34 a.m., CNA D said if a resident tested positive for COVID they would be placed in isolation and staff would wear N95 masks while in the building. CNA D said the COVID positive resident would be in isolation for 10-12 days. CNA D said if a resident was exposed to COVID but tested negative for COVID they would not be moved or put in isolation. CNA D said Resident #1 was the only resident she was ever aware of refusing to be COVID tested. CNA D said Resident #1 was placed on isolation in the summer 2023 during a COVID outbreak for the duration of the outbreak. During an interview on 2/15/24 at 10:38 a.m., LVN E said she had worked at the facility for 12 years. LVN E said if a resident tested positive for COVID, they would be placed in isolation, the facility would begin outbreak testing, and staff would wear N95 masks while in the facility. LVN E said a COVID positive resident would be in isolation for 10 days. LVN E said if a resident was exposed to COVID, was symptomatic, and tested negative for COVID they would be placed in isolation for 7-10 days or until they were no longer symptomatic. LVN E said if a resident refused to be COVID tested and were asymptomatic they would be put in isolation because the facility would not know if they were COVID positive. LVN E said a resident who refused to be COVID tested would be in isolation until they agreed to be tested. LVN E said if a resident was non-compliant with isolation, staff would educate the resident, contain to illness, wound, etc ., and perform/encourage frequent hand hygiene. During an interview on 2/15/24 at 12:58 pm, the DON said if the facility had a COVID positive resident, they would begin outbreak testing on days 1, 3, and 5, and isolate the COVID positive resident for 10 days. The DON said in July 2023, the facility was considered in outbreak until they went 14 days without a COVID positive test. The DON said if a resident had been exposed to COVID, was symptomatic, and tested negative they would not be put in isolation. The DON said if a resident refused to test for COVID, they would be put in isolation until the facility was out of outbreak. The DON said Resident #1 refused to be COVID tested and was placed in isolation for the duration of the outbreak that occurred in the summer of 2023. The DON said Resident #1 was asymptomatic during the isolation and outbreak. The DON said Resident #1 only interacted with other resident while in therapy, when eating in the dining room, and sometimes when brought to activities by his family, but for the most part was not around other residents a lot. The DON said if the facility had ended Resident #1's isolation after 10 days, and they were still in outbreak, he would have been re-exposed and required another 10-day isolation. The DON said Resident #1 was isolated during the facility's COVID outbreak in November 2023. During an interview on 2/20/24 at 1:06 p.m., Resident #1's family said on 8/16/23, they took 676048 Page 9 of 12 676048 02/22/2024 Legend Oaks Healthcare and Rehabilitation Center - 1201 Fm 2685 Gladewater, TX 75647

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #1 outside and were yelled at by the DON to go back to the Resident #1's room. The family said Resident #1 started crying when the DON yelled at them . The family said during the October COVID isolation Resident #1 was isolated for 3 weeks after they had been told it would only be a 14-day isolation. They said Resident #1 was put in isolation again in November due to another COVID outbreak at the facility and refusal to COVID test. The family said during one of his isolations they had taken Resident #1 outside to the front porch of the facility and away from other residents. The family said the Administrator came out and told them they could not be outside or out of the room. The family said she asked why as they were not near any other person. The family said they were wearing masks at the time. The family said the Administrator said something about Resident #1 shedding and it was blowing towards him, and he could get COVID from the shedding. The family said the Administrator continued to stand there looking at them and Resident #1 began to get upset so she reluctantly took Resident #1 back to his room. During an interview on 2/21/24 at 1:15 p.m. the DON said during his isolation, Resident #1 was permitted to go outside. The DON said there were stipulations on him going outside. The DON said the stipulations included Resident #1 had to wear a mask when transporting through the facility and had to come back in or wear a mask if other residents were outside. The DON said there were only 2 sitting areas outside and she guessed they were only about 4 feet apart, but she had not measured it. 2. Record review of a face sheet dated 2/22/24 indicated Resident #2 was re-admitted to the facility on [DATE] with diagnoses including hypertension (elevated blood pressured), anxiety, muscle weakness, repeated falls, and hemiplegia affecting the left side. Record review of the MDS dated [DATE] indicated Resident #2 was understood by others and usually understood others. The MDS indicated Resident #2 had a BIMS of 12 and was moderately cognitively impaired. The MDS indicated Resident #2 was incontinent of bladder and bowel and required maximum assistance with toileting. Record review of the care plan last revised 7/11/23 indicated Resident #2 had an ADL Self-Care Performance Deficit related to impaired balance, weakness, and impaired. During an observation on 2/13/24 at 11:11 a.m., CNA F and CNA G performed incontinent care on Resident #2. Both CNAs performed hand hygiene prior to starting incontinent care and changed gloves as needed performing hand hygiene between glove changes. CNA F dropped 2 wipes onto the draw pad, picked them up, and them used them to clean Resident #2's peri-area (tiny patch of sensitive skin between your genitals (vaginal opening or scrotum) and anus, and it is also the bottom region of your pelvic area). CNA F later, during a glove change, dropped a glove onto the draw pad, picked it up and put it on to continue performing incontinent care. During an interview on 2/13/24 at 11:23 a.m., CNA G said the draw pad would be considered dirty due to the dirty brief being on it. During an interview on 2/13/24 at 11:24 a.m. CNA F said the draw pad would be considered dirty. CNA F said gloves or wipes dropped on the draw pad during incontinent care would be considered contaminated. CNA F said she should not have used the wipes or glove that had fallen on the draw pad that she should have thrown them away and got clean supplies. CNA F said the importance of not using contaminated supplies was for infection control. During an interview on 2/15/24 at 9:33 a.m., the Infection Preventionist said if, during peri-care, 676048 Page 10 of 12 676048 02/22/2024 Legend Oaks Healthcare and Rehabilitation Center - 1201 Fm 2685 Gladewater, TX 75647

F 0880 Level of Harm - Minimal harm or potential for actual harm a glove or wipes were dropped on a draw pad, they might be considered dirty if staff was unsure if the draw pad was clean. The Infection Preventionist said best practice would be to dispose of any wipes or gloves that were dropped on a draw pad and not use them on the resident. The Infection Preventionist said the importance of not using wipes or gloves on a resident that were dropped on a draw pad was because one didn't know if the draw pad was clean. Residents Affected - Some During an interview on 2/15/24 at 10:38 a.m., LVN E said she was unsure if a wipe and glove dropped on the draw pad during incontinent care would be considered contaminated. LVN E said after consulting with coworkers, a glove or wipes dropped on a draw pad would be considered contaminated. LVN E said if dropped on the draw pad during incontinent care, the glove and wipes should be disposed of and not used. LVN E said the importance of disposing of a glove or wipes that had been dropped during incontinent care was to prevent the spread of bacteria. During an interview on 2/15/24 at 12:58 p.m., the DON said if, during incontinent care, wipes or a clean glove were dropped on a draw pad, she was not sure if they would be considered contaminated. The DON said if the brief had been opened and was dirty, then she would consider dropped wipes or gloves contaminated. The DON said she did not know how to answer what she expected her staff to do if they dropped wipes or gloves on the draw pad during incontinent care since it was not a sterile procedure. The DON said the reason contaminated items should not be used during incontinent care was for infection control. Record review of the facility's Surveillance of Infections and Reporting policy last revised 9/2017 indicated, It is the policy of this facility to maintain an ongoing system of surveillance designed to identify possible communicable diseases or infections to ensure that measures are take to prevent any potential outbreak .During the initial assessment, the physician or provider will help identify individuals who have had a recent infection or who are at risk for developing an infection. Infection may be suspected based on clinical signs and symptoms: i. Temperature elevation over 101 degrees Fahrenheit, ii. A draining wound, iii. Receiving special treatment such as compresses, heat treatment, etc., iv. Receiving Antibiotics, v. If culture is obtained for any reason, vi. Has an abnormal chest x-ray indicative of an infiltrate or infectious lesion, vii. admitted with a suspected or confirmed infection, viii. Had positive culture report, ix. Cough-producing yellowish or green sputum, x. Rash or pustules of unknown origin, xi. Nausea/Vomiting/Diarrhea, xii. Persistent eye irritation with exudate .Residents should be allowed to ambulate, interact with other residents socially and participate in group activities. It is the philosophy of the facility to isolate the infection (the germ), not necessarily the resident. Record review of the facility's Incontinent Care policy revised 5/2007 indicated, It is the policy of this facility to: Remove urine or feces from the skin, Cleanse and lubricate the skin, Provide dry, odor free perennial (tiny patch of sensitive skin between your genitals (vaginal opening or scrotum) and anus, and it is also the bottom region of your pelvic area) care system . Record review of the facility's COVID-19 Testing policy revised 10/2022 indicated, It is the policy of this facility to provide or obtain laboratory testing services for residents and staff to assist in the identification and management of COVID-19 infections and/or outbreaks. Testing will be performed according to current local/state health departments and Centers for Disease Control and Prevention guidelines .Resident declines: Resident or resident representatives my exercise their right to decline COVID-19 testing. A. If a resident has known exposure to COVID-19 or is symptomatic regardless of vaccination status and declines testing, the resident will be placed on transmission-based precautions (TBP) until criteria for discontinuation is met. B. If outbreak testing has been triggered 676048 Page 11 of 12 676048 02/22/2024 Legend Oaks Healthcare and Rehabilitation Center - 1201 Fm 2685 Gladewater, TX 75647

F 0880 Level of Harm - Minimal harm or potential for actual harm and an asymptomatic resident refuses testing, the facility should be extremely vigilant, such as through additional monitoring, to ensure the resident maintains the appropriate distance from the other residents, wears a face covering, and practices effective hand hygiene until the procedures for outbreak testing have been completed . Residents Affected - Some 676048 Page 12 of 12