Health inspection·January 29, 2026

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her supplies. The family member stated she left the facility around 6:20 p.m. and CNA B had not returned to provide assistance. The family member stated she sat in the parking lot for approximately 20 minutes and left around 6:40 p.m. The family member stated she assumed care had been provided because Resident #1 did not call her. The family member stated Resident #1 called her around 7:30 p.m. and was audibly upset and in distress. Resident #1 reported that she had still not been changed, and CNA B came into her room, refused to change her, give her name, and stuck her tongue out at her. The family member stated she immediately came up to the facility, confronted CNA B and reported the allegations to the Administrator. During an interview on 01/28/2026 beginning at 8:26 p.m., CNA B stated she was fairly new to the facility and had started around 01/02/2026. She stated she was still working at the facility but was moved off Resident #1's hallway. She said she had only worked 2 days on Resident #1's hallway. She stated Resident #1 did not normally get on her call light, but she was aware Resident #1 was incontinent of her bowels. CNA B stated on 01/19/2026 around 6:10 p.m., Resident #1's family member reported that Resident #1 had diarrhea and needed to be changed. She said she told Resident #1's family member she had just arrived at work and was going to gather her supplies. CNA B stated she changed Resident #1 around 6:20 p.m. and she had just started having a bowel movement but there was no diarrhea. CNA B said she finished changing Resident #1 and told her she would return later to allow her time to finish having a bowel movement. CNA B stated she returned 35 - 40 minutes later and changed Resident #1 a second time. She said Resident #1 had no diarrhea. CNA B stated she was providing care for another resident when Resident #1's family member started asking her questions in a rude tone. CNA B stated the family member accused her of letting Resident #1 sit in her bowel movement for hours, refusing to introduce herself or give Resident #1 her name, and sticking her tongue out at her and rolling her shoulders. CNA B stated she did not stick her tongue out or roll her eyes. She said she re-introduced herself each time she went into the room. She said the Administrator arrived at the facility, explained the allegations were considered neglect and suspended her pending an investigation. CNA B stated she left the facility. During an interview on 01/29/2026 beginning at 12:05 p.m., the Administrator stated on 01/19/2026 he received a call from Resident #1's family member around 8:30 p.m. He said the family was upset that Resident #1 had several large bowel movements and hadn't been changed for two hours. The Administrator said when he arrived at the facility, Resident #1 reported CNA B had come into her room, stated she would be back and turned off the call light, stuck her tongue out at her and rolled her eyes. The Administrator stated he found CNA B and informed her she was suspended pending the investigation and sent her home. The Administrator stated Resident #1 had no evidence of distress and he felt the allegation was more related to customer service versus neglect, which was why he decided not to report the incident to HHSC. The Administrator was unsure of the actual time it took for Resident #1 to receive assistance. The Administrator stated he completed safe surveys and found no further complaints about CNA B. He said there were no resident complaints about call lights not being answered. He said the nurses performed a skin assessment on Resident #1 with no abnormal findings. The Administrator stated neglect was when the facility did not give care, that resulted in further injuries. The Administrator stated there had to be harm or injuries to have been considered neglect. He stated the abuse policy should have been followed, and he felt like he followed the reporting guidelines. The Administrator stated he referenced the state provider letter on abuse reporting and his policy when determining whether an allegation needed to be reported. He said he could also contact several resources within the company. Record review of the 7 safe surveys, dated 01/20/2026, reflected Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, and Resident #8 felt safe in the facility and had no issues or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676048 If continuation sheet Page 2 of 3 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 01/29/2026 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete concerns with the staff members at the facility. Record review of the Abuse: Prevention of and Prohibition Against policy, last revised in April 2025, reflected Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect includes cases where the facility's indifference or disregard for resident care, comfort, or safety, resulted in or could have resulted in, physical harm, pain, mental anguish, or emotional distress. All allegations of abuse, neglect. should be reported immediately to the Administrator. Allegations of abuse, neglect. will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations. Event ID: Facility ID: 676048 If continuation sheet Page 3 of 3