Health inspection·January 21, 2026

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 failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accident hazards. The facility failed to ensure Resident #1 had appropriate footwear on while she sat in her wheelchair in the dining room on 1/21/26. This failure could place residents at risk of falls and significant injury. Findings included: Record review of Resident #1's face sheet dated 1/21/26 indicated she was an [AGE] year-old female readmitted to the facility on [DATE] with diagnoses including heart failure, chronic respiratory failure, muscle wasting and atrophy, dementia, lack of coordination, and history of falling. Record review of the MDS dated [DATE] indicated Resident #1 usually made herself understood and usually understood others. The MDS indicated Resident #1 had moderate cognitive impairment (BIMS of 12). The MDS indicated Resident #1 used a wheelchair for mobility. The MDS indicated Resident #1 required substantial/maximal assistance with toileting, showers/bathing, lower body dressing and putting on/taking off footwear. The MDS indicated Resident #1 required partial/moderate assistance with oral hygiene, upper body dressing and personal hygiene. The MDS indicated Resident #1 required set up or clean-up assistance with eating. The MDS indicated Resident #1 required substantial/maximal assistance with tub/shower transfers, toilet transfers, chair/bed-to-chair transfers and with sit to stand. The MDS indicated Resident #1 required partial/moderate assistance with rolling to the left and the right, transitioning from a sitting position to a lying position and lying to sitting on the side of the bed. The MDS indicated Resident #1 could independently wheel herself in her manual wheelchair. The MDS indicated she was incontinent of bowel and bladder. Record review of Resident #1's care plan revised on 1/8/26 detailed she was at risk for falls with actual falls on 11/7/25, 11/11/25, 12/6/25 and 1/8/26. The care plan interventions included, anticipate/meet needs and follow facility fall protocol. Record review of incident reports for Resident #1 for November 2025-January 2026 revealed Resident #1 had falls on the following dates; -11/7/2025- no injuries were found; -11/11/2025- no injuries were found;-12/6/2025- no injuries were found; and -1/8/26- sustained a bruise to face and hematoma to face, Resident #1 was sent to the hospital for evaluation. Improper footwear was not selected as a pre-disposing factor with any of the falls. During an observation on 1/21/26 at 12:05 p.m., Resident #1 self-propelled in her wheelchair (by using her feet) into the dining room. The socks to her feet were red and green with no anti-slip surface to the soles. During an observation on 1/21/26 at 2:05 p.m., Resident #1 sat in her wheelchair in the dining room playing bingo. The socks to her feet were red and green with no anti-slip surface to the soles. The sock to the left foot was slipped down beneath her heel. During an interview on 1/21/26 at 2:15 p.m., RN A said Resident #1 was a major fall risk with recent fall injury and lack of safety awareness. RN A said it was important to ensure Resident #1 had appropriate footwear on her feet. During an (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 676048 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 01/21/2026 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)