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 Page 1 of 2 676048 676048 01/21/2026 Legend Oaks Healthcare and Rehabilitation Center - 1201 Fm 2685 Gladewater, TX 75647

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interview on 1/21/26 at 2:20 p.m., CNA B said fall interventions for at risk residents included wearing anti-slip socks or shoes. During an interview and observation on 1/21/26 at 2:30 p.m., CNA C said she was the assigned CNA for Resident #1 on the 6:00 a.m.- 6:00 p.m. shift. CNA C said fall interventions for at risk residents included wearing anti-slip socks or shoes. CNA C said Resident #1 should have had anti-slip footwear on to prevent falls and potential injuries. During an interview on 1/21/26 at 3:00 p.m., LVN D said she was the nurse assigned to Resident #1 on the 6:00 a.m.- 6:00 p.m. shift. LVN D said Resident #1 was a significant risk for falls with recent fall from her bed resulting in injury. LVN D said Resident #1 should have had anti-slip footwear on her feet. LVN D not having appropriate footwear on in the dining room could result in additional fall and injury. During an interview on 1/21/26 at 3:05 p.m., ADON E said it was important for Resident #1 to have appropriate footwear on her feet because not having slip-resistant footwear could result in her (Resident #1) falling again. During an interview on 1/21/26 at 4:54 p.m., the Administrator said he expected staff to encourage residents to wear appropriate footwear to decrease fall risk. Record review of the facility policy and procedure dated December of 2023, titled Fall management system, stated, It is the policy of this facility to provide and environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. 676048 Page 2 of 2