Health inspection·August 17, 2023

F 0689 and falls were documented: Level of Harm - Immediate jeopardy to resident health or safety [DATE] - fall with left hip and low back pain Residents Affected - Few [DATE] - fall with no injuries [DATE] - fall with skin tear [DATE] - fall with hematoma (swollen bruise) to forehead [DATE] - fall no injuries [DATE] - fall with skin tear to left lateral (outside) upper arm, bruise to left lateral (outside) antecubital (inside of elbow) area, abrasion (scratch) to left posterior (back) ribs/flank area [DATE] - fell, hit head, left rib area The care plan was updated for falls on the following dates: [DATE] PT working with resident on strength training [DATE] nursing staff will keep door open for better monitoring [DATE] floor mats at bedside Interventions included re-orient resident to call light ([DATE]), appropriate footwear ([DATE]), safe environment with clean floor, free of clutter, adequate light, bed in low position, side rails on bed, hand rails on walls, personal items in reach ([DATE]), physical therapy to strengthen resident ([DATE]), keep door open ([DATE]). Review of Resident #1's order history printed [DATE] revealed the following orders: 'Scoop mattress on bed due to frequent falls and impaired safety awareness, start date [DATE], no end date Monitor placement and functioning of wander guard every shift, start date [DATE], end date [DATE] BusPIRone HCl Tablet 15 MG Give 1 tablet by mouth three times a day for anxiety, start date [DATE], no end date Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium) Give 1 tablet by mouth two times a day related to DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, SEVERE, WITH PSYCHOTIC DISTURBANCE, start date [DATE], no end date Cymbalta Capsule Delayed Release Particles 60 MG (DULoxetine HCl) Give 1 capsule by mouth one time a day related to OTHER RECURRENT DEPRESSIVE DISORDERS, start date [DATE], no end date Haloperidol Lactate Concentrate 2 MG/ML Give 0.5 ml by mouth every 6 hours as needed for agitation, start date [DATE], end date [DATE] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676253 If continuation sheet Page 2 of 6 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 676253 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation - Ennis 1400 Medical Center Drive Ennis, TX 75119 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 - Immediate jeopardy to resident health or safety Residents Affected - Few LORazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 6 hours as needed for anxiety for 14 Days, start date [DATE], end date [DATE] LORazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 6 hours as needed for anxiety, start date [DATE], end date [DATE] LORazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 6 hours as needed for anxiety for 30 Days, start date [DATE], end date [DATE] tiZANidine HCl Tablet 2 MG Give 1 tablet by mouth at bedtime for muscle spasm, start date [DATE], no end date TraMADol HCl Tablet 50 MG Give 1 tablet by mouth two times a day related to OTHER MUSCLE SPASM, start date [DATE], no end date Vistaril Oral Capsule (Hydroxyzine Pamoate) Give 10 mg by mouth every 12 hours as needed for anxiety/agitation, start date [DATE], end date [DATE] Vistaril Oral Capsule 25 MG (Hydroxyzine Pamoate) Give 1 capsule by mouth every 24 hours as needed for anxiety related to ANXIETY DISORDER, UNSPECIFIED (F41.9) for 30 Days, start date [DATE], end date [DATE] Vistaril Oral Capsule 25 MG (Hydroxyzine Pamoate) Give 1 capsule by mouth two times a day related to ANXIETY DISORDER, UNSPECIFIED (F41.9), start date [DATE], end date [DATE]. Vistaril Oral Capsule 25 MG (Hydroxyzine Pamoate) Give 1 capsule by mouth two times a day related to ANXIETY DISORDER, UNSPECIFIED (F41.9); DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, SEVERE, WITH PSYCHOTIC DISTURBANCE, start date [DATE], no end date' 'Cipro Oral Tablet 500 MG Give 1 tablet by mouth every 12 hours related to urinary tract infection, for 7 Days, start date [DATE], end date [DATE] Ertapenem Sodium Injection Solution Inject 1 gram intramuscularly every 24 hours for infection related to urinary tract infection for 7 Days, start date [DATE], end date [DATE].' Review of the list of Resident #1's fall incidents for the last 12 months revealed 14 falls on the following dates: [DATE] [DATE] [DATE] [DATE] [DATE] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676253 If continuation sheet Page 3 of 6 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 676253 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation - Ennis 1400 Medical Center Drive Ennis, TX 75119 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 [DATE] Level of Harm - Immediate jeopardy to resident health or safety [DATE] Residents Affected - Few [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] Record review of Resident #1's fall incident reports revealed: [DATE] Resident #1 was found prone at the foot of room mate's bed; Resident #1 stated she was exiting the restroom; no injuries noted [DATE] Resident #1 was found laying face down leaning on her right shoulder, unable to describe what occurred; had a hematoma to top of right forehead. [DATE] Resident #1 was sitting on buttocks on the floor between wheelchair and closet; no injuries found; unable to decribe incident [DATE] crshign noise heard, Resident #1 found on ground moaning and grimacing; no head injury, skin tear to upper arm; left side tender to touch; x-ray of spine and left pelvis done without injries; resident unable to verbalize incident [DATE] Sound was heard, Resident #1 was found lying on her right side with a pool of blood around her During an interview and observation on [DATE] beginning at 10:00 am with Resident #1, she was sitting in a wheelchair across from the nurses station and smiled and said hi. She did not appear in pain, but a healing cut to the right forehead was visible as were several bruises to both of her arms and a few small cuts/scratches were visible on both arms as well. The resident was not interviewable due to her dementia. During an interview on [DATE] at 4:28 pm RP, stated that in July Resident #1 was having an increase in her falls, so she asked the facility to discontinue the Vistaril because she thought it was causing the falls; the facility told RP that the doctor made the Vistaril PRN but did not want it discontinued. RP stated that Resident #1 went to the hospital because of a fall with a knot on her head on [DATE], and then Resident #1 was confused and had altered mental status on [DATE] and was diagnosed with a urinary tract infection. RP said that Resident #1 had a bad fall on [DATE] and was admitted to the hospital because the facility couldn't stop the bleeding and were concerned about head (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676253 If continuation sheet Page 4 of 6 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 676253 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation - Ennis 1400 Medical Center Drive Ennis, TX 75119 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 trauma; Resident #1 was diagnosed with 3 broken ribs on the left. Level of Harm - Immediate jeopardy to resident health or safety During an interview on [DATE] at 12:30 pm ADM, stated that Resident #1 was having altered mental status, so psychiatry was consulted and started the resident on Depakote on [DATE]. She stated the resident was sent to the emergency room [DATE] and was diagnosed with a urinary tract infection and started on one antibiotic (cipro), and then it was switched to a stronger antibiotic when sensitivities returned (Ertapenem). She stated that psychiatry was aware of the falls that Resident #1 suffered and did not want to discontinue Vistaril. Residents Affected - Few During an interview on [DATE] at 3:23 pm Psych MD, stated that Depakote could cause falls and dizziness, as could Vistaril. He stated he would discontinue any medication if the RP requested it because it was the withdrawal of consent for the medication. He denied knowledge of the request to discontinue Vistaril but did change it to PRN because the RP was concerned about the falls. He was informed the resident would not stay in the wheelchair and was having falls, so he added Depakote and resumed scheduled Vistaril. He stated that he was not aware that Resident #1 was diagnosed with a UTI on the same day as the Depakote was started and that Resident #1's confusion and agitation could have been caused by the UTI and not progression of disease and he would have discontinued the Depakote if he had known. He also stated he complied with recommendations from the pharmacist, for dose reductions. During an interview on [DATE] at 5:51 pm ADON stated that on [DATE] she and RP saw Resident #1 was agitated and looking for her deceased husband, so she saw Psych MD and got order for Vistaril 10 mg twice a day PRN and that RP gave verbal consent. She stated that Resident #1's diagnosis of UTI was discussed at the morning meeting, but that she did not use her clinical judgement to consider discontinuing the new psychotropic medications that were added due to the altered mental status of the resident. Record review of Resident #1's progress notes dated [DATE] revealed a note at 9:34 am that stated resident with increased anxiety and pressured speech; aggressive behaviors with staff redirected with difficulty, NP present and new order for Depakote 125 mg bid for psychosis and mood disorder, RP aware and gave verbal consent. Further review revealed a progress note dated [DATE] at 12:35 pm that stated that Resident #1 was sent to the emergency room due to altered mental status and agitation and returned with a diagnosis of UTI. Record review of the manufacturer's guidelines for Depakote, accessed on [DATE] at https://www.depakote.com/hcp/important-safety-information revealed: In a clinical trial, somnolence was associated with valproate in some elderly dementia patients along with reduced nutritional intake; weight loss; and a trend to have a lower baseline albumin concentration, higher BUN, and lower valproate clearance. Discontinuation occurred in some patients. It further revealed that the most common adverse reactions (reported >5%) included accidental injury, blurred vision, amnesia, anorexia, depression, dizziness, dyspepsia (indigestion), emotional lability (rapid mood changes), insomnia, nausea, nervousness, rash, somnolence (drowsiness), thinking abnormal, tremor, vomiting, and weight loss. Record review of the [DATE] Beers Criteria for Potentially Inappropriate Medication Use in Older Adults published by the American Geriatrics Society, accessed on [DATE] at https://www.guidelinecentral.com/guideline/340784/ , revealed that Cymbalta (duloxetine) should be used with caution, haloperidol should be avoided except in some situations (bipolar, schizophrenia, and short term chemotherapy), Vistaril (hydroxyzine) should be avoided for strong anticholinergic properties (impaired memory, reduced cognitive function, behavioral disturbances, anxiety, and insomnia), Lorazepam should be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676253 If continuation sheet Page 5 of 6 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 676253 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation - Ennis 1400 Medical Center Drive Ennis, TX 75119 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 avoided, and tramadol should be used with caution. Level of Harm - Immediate jeopardy to resident health or safety Record review of the admission Drug Regimen Review performed [DATE] for Resident #1's readmission from the hospital revealed: No use of medication(s) without evidence of adequate indication for use; No history of recent adverse reactions to any medication; No duplicate therapy and was signed by LVN A. Residents Affected - Few Record review of the hospital records of Resident #1's (hospital) admission on [DATE] revealed a right forehead laceration; a CT of the abdomen and pelvis with contrast revealed acute minimally displaced nonsegmental fractures of the left 8th, 9th and 10th ribs. Record review of the Pharmacist recommendation for [DATE] to review Cymbalta (duloxetine) and buspirone for reduction in dose revealed the Psych NP declined GDR on [DATE] because a decrease would result in return of symptoms. Record review of the [DATE] Psych NP visit summary revealed no mention of diagnosis of urinary tract infection on [DATE], nor change of antibiotics on [DATE]. Record review of the facility's Falls Prevention Policy dated [DATE] revealed: . a review of all falls will be completed, with the purpose of . investigating the circumstances surrounding each resident fall and implement actions to reduce the incidence of additional falls and minimize potential for injury . discussions may include: .Recent medication changes . Lab studies . Medical status FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676253 If continuation sheet Page 6 of 6