Health inspection·January 11, 2024

F 0689 wheelchair, and she stated, It was needing some work. There were no skin tears on arms. Level of Harm - Minimal harm or potential for actual harm Review of Resident #33's quarterly MDS assessment, dated 12/18/23, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses of Cardiovascular disease (stroke) hemiplegia (partial weakness on same side of the body), Hemiparesis (partial weakness on one side of the body), difficulty in walking, and muscle weakness. Residents Affected - Some Review of the Resident #33's updated plan of care dated 12/02/23 with updates reflected goals and approaches to include wheelchair mobility. Observation on 01/09/24 at 1:25 p.m. revealed Resident #33 was in her wheelchair, and the wheelchair's right and left armrests were cracked with the foam exposed. There were no skin tears on arms. Review of Resident #35's quarterly MDS assessment, dated 12/10/23, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses of Parkinson (instability neuromuscular disorder) and lack of coordination and weakness. Review of the Resident #35's updated plan of care dated 11/07/23 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 01/09/24 at 1:30 p.m. revealed Resident #35 was in his wheelchair and with no skin problems. The wheelchair's right armrest and the left armrest were cracked with the foam exposed. Resident #35 was asked about the wheelchair, and he stated the handles were rough. Review of Resident #47's quarterly MDS assessment, dated 11/12/23, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses of epilepsy (seizures), abnormality of gait and mobility, and instability of left knee. Review of the Resident #47's updated plan of care dated 10/08/23 with updates reflected goals and approaches to include wheelchair mobility and skin not being in contact with hard surfaces since she has thin skin and a history of skin tears on her hands. Observation on 01/09/24 at 1:45 p.m. revealed Resident #47 was in her wheelchair and had no skin problems. The wheelchair's left and right armrests were cracked with the foam exposed. Resident #47 was unable to be interviewed. In an interview on 01/10/24 at 12:27 p.m. CNA E stated when a resident's wheelchair needed repair the staff were to enter it into electronic maintenance system in the computer. CNA E stated she had never written anything in the computer though she usually told the nurse in charge. In an interview on 01/10/24 at 12:30 p.m. LVN A stated when a resident's wheelchair needed repair the staff were to write it in electronic maintenance system, tell the maintenance man, who would tell them to place the information in electronic maintenance system and try to find a new wheelchair that was not being used. In an interview on 01/11/24 at 9:46 a.m. the Maintenance Supervisor stated he repaired the wheelchairs when there was needed repairs. He stated staff were to place the needed repairs in TELs. The Maintenance Supervisor was informed about the residents' wheelchairs condition, and he stated if the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676253 If continuation sheet Page 2 of 8 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 01/11/2024 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 - Minimal harm or potential for actual harm Residents Affected - Some wheelchairs' issues had not been placed in TELs for repair he would not know. The Maintenance Supervisor stated that all staff could place information about needed repairs in TELs. A review of the electronic maintenance system with the Maintenance Supervisor on 01/11/23 reflected there were no entries that indicated residents' wheelchairs needed the armrest repaired for the October -December 2023. A review of the facility's policy and procedure Maintenance dated July 2018 reflected It is the policy of this community to maintain all equipment provided by the facility, in good working order to ensure the safety and wellbeing of all residents and staff Equipment provided by the community will be: 1. Maintained in working order. A review for the facility's policy and procedure Maintenance and subject maintenance services dated July 2018 reflected: It is the policy of the facility to maintain a clean and safe facility and grounds. A Maintenance problems or concerns must be reported to the office and work order will be generated. Procedure: 1. When a maintenance issue arises, the resident, staff member or family member must put in a work order 2. The maintenance department will complete the work order within 72 hours from the time it was reported . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676253 If continuation sheet Page 3 of 8 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 01/11/2024 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 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** Residents Affected - Some Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for five (Residents #6, #8, #9, #28 and #50) of 7 residents reviewed for infection control. MA C failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #50, #9, and #28. MA D failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #8, and #6. The failures could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Review of Resident #8's EHR revealed the resident was a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses including Hypertension, with diagnoses of CVA (Stroke), hypertension (increased blood pressure), hemiplegia (partial weakness on same side of the body) and hemiparesis (partial weakness on one side of the body) effecting the nondominated side. Review of Resident #8's quarterly MDS assessment, dated 10/18/23, reflected a BIMs score of 14, indicating the resident was alert and oriented, capable of making decisions. His functional status indicate he needed one staff to complete his activities of daily living. Record review of Resident #8's physician orders dated 12/24/23 reflected, Amiodarone HCL tabs 200 mg one time a day for arrhythmia. Take Blood pressure every day. Review of Resident #6's EHR revealed the resident was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including Hypertension (increased blood pressure) and coronary artery disease (coronary arteries blocked). Review of Resident #6's quarterly MDS, dated [DATE] revealed a BIMs score of 14, indicating she was alert and oriented not impaired for decision making, her functional status indicated she needed assist of one staff with her activities of daily living. Record review of Resident #6's physician orders dated 01/03/24 reflected, Bumex oral tab 1mg every day, Doxazosin mesylate (blood pressure) tab 8 mg two times as day, and hydralazine 100 mg (blood pressure) three times a day. Review of Resident #9's EHR revealed the resident was a [AGE] year-old female that was admitted to the facility on [DATE], with diagnosis including essential Hypertension (elevated blood pressure). Review of Resident #9's quarterly MDS, dated [DATE] revealed a BIMs score of 11, indicating she was alert and oriented and not impaired for decision making, her functional status indicated she needed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676253 If continuation sheet Page 4 of 8 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 01/11/2024 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 0880 assist of two staff with her ADLs. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #9's physician orders dated 12/11/23 reflected, metoprolol ER (blood pressure) 25 mg every day and lisinopril (blood pressure med) 1-tab 5 mg every day. Checking blood pressure prior to administration. Residents Affected - Some Review of Resident #28's EHR revealed the resident was an [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including elevated blood pressure without a diagnosis of hypertension and Parkinson. Review of Resident #28's quarterly MDS, dated [DATE] revealed a BIMs score of 15, indicating she was alert and oriented, not impaired for decision making, her functional status indicated she needed assist of one staff with her ADLs. Record review of Resident #28's physician orders dated 12/01/23 reflected, Amlodipine Besylate (blood pressure) 10 mg every day and hydralazine (blood pressure) 100 mg three times a day. Checking blood pressure prior to administration. Review of Resident 50's EHR revealed the resident was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including hypertension (elevated blood pressure). Review of Resident #50's quarterly MDS, dated [DATE] revealed a BIMs score of 9, indicating she was confused and impaired for decision making, her functional status indicated she needed assist of one staff with her ADLs. Record review of Resident #50's physician orders dated reflected, Cozaar (blood pressure) 100 mg every day and nifedipine ER (blood pressure) 60 mg every day. Checking blood pressure prior to administration. Observation on 01/10/24 at 8:17 a.m. revealed MA C performing morning medication pass, during which time she checked the blood pressure of Resident #50. MA C failed to sanitize the blood pressure cuff before or after using it on Resident #50. Observation on 01/10/24 at 8:20 a.m. MA C performing a medication pass, during which time she checked the blood pressure of Resident #9. MA C failed to sanitize the blood pressure cuff before or after using it on Resident #9. Observation on 01/10/24 at 8:36 a.m. revealed MA C performing a medication pass, during which time she checked the blood pressure of Resident #28. MA C failed to sanitize the blood pressure cuff before or after using it on Resident #28. Observation on 01/10/24 at 8:59 a.m. revealed MA D performing morning medication pass, during which time she checked the blood pressure of Resident #8. MA D failed to sanitize the blood pressure cuff before or after using it on Resident #8. Observation on 01/10/24 at 9:13 a.m. revealed MA D performing a morning medication pass, during which time she checked the blood pressure of Resident #6. MA D failed to sanitize the blood pressure cuff before or after using it on Resident # 6. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676253 If continuation sheet Page 5 of 8 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 01/11/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Interview on 01/10/24 at 8:42 a.m., MA C stated she always cleaned the blood pressure cuff with the purple top before and after each use. MA C stated she had used the purple top wipes that were on her medication cart to clean the blood pressure cuff and stated, you must have missed that part. She stated there had been in-services on infection control and cleaning equipment, but she could not recall when that had occurred. MA C stated that if the cuff was not cleaned appropriately, it could spread germs. Residents Affected - Some Interview on 01/10/24 at 9:15 a.m., MA D stated blood pressure cuffs should be sanitized with wipes between each resident use to prevent transmitting an infection from one resident to another. She stated she was supposed to cleanse the blood pressure cuff in-between each usage. MA D stated she had been nervous because she had never had to perform her medication pass in front of a state surveyor. MA D stated that if the equipment that was used on the residents was not cleaned correctly it could cross contaminate causing a spread of infection. Interview on 01/10/23 at 4:19 p.m. with the DON she stated that her expectation was that staff would sanitize all reusable equipment between each resident use. She stated that not doing so placed residents at risk of cross contamination of infections from one resident to another. She stated there was plenty of supplies for the nursing staff to have the sanitization wipes that were EPA-registered disinfectant, on all the medication carts. The DON stated there had recently been an in-service for the staff on infection control and cleaning equipment. Review of the in-service records dated 10/16/23 reflected in service training topic cleaning essential equipment: blood pressure cuffs, glucometers, treatment supplies disinfection MA C's and MA D's names were on the list and further review reflected follow-up activity with competencies review there was no presented follow-up competencies reports. Review of facility's Policies and Procedure titled: Infection control and Sanitation, revision date October 2022, reflected the following: The infection control prevention and control program is a facility -wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program . The program will be carried out by the facility infection control preventionist. It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers based on acceptable standards . Goals: decrease the risk of infection to resident and personnel, recognize infection control practices while providing care, identify and correct problems relating to infection control, ensure compliance with state and federal regulations related to infection control 6. c. effective cleaning and disinfecting equipment as needed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676253 If continuation sheet Page 6 of 8 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 01/11/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for one (200, 300,400Hall) of two halls and 1 of 1 dining room reviewed for environment. The facility failed to ensure windows, floors, and ceilings were in good repair for halls 200, 300,400, dining room, and the 200-300 hall shower room. This failure could affect residents and the staff by placing them at risk for diminished quality of life due to the lack of a well-kept environment. Findings included: An observation on 01/10/24 at 9:00 AM revealed that the ceiling in the hallway near the entrance to room [ROOM NUMBER] had a 5-inch by 2-inch section of paint and ceiling material hanging down. An observation on 01/10/24 at 9:04 AM revealed that the faux wood flooring at the entrances to the 300 and 400 halls had a black gummy build up between the joints and along the edges of the faux wood tiles. An observation on 01/10/24 at 9:08 AM revealed that 8 panes in the windows on the left side of the dining area were cracked and the entire cabinet unit at the back of the dining room had pulled away from the wall revealing a 2-inch gap between the cabinetry and the wall. An observation on 01/10/24 at 9:14 AM revealed that the left-hand shower stall of the two shower stalls in the 200-300 hall shower room was missing a handle to activate and control the water temperature of the shower. An observation on 01/10/24 at 9:26 AM revealed spiderwebs and various small debris behind the fire doors of the 200, 300, and 400 halls. Interview on 01/10/24 at 12:45 PM, RN F revealed that any broken equipment or facility fixtures had to be logged into the TEL's system, electronic maintenance system, and that all personnel in the facility had access to and had been trained on using the TEL's system. Interview on 01/10/24 at 1:00 PM, LVN A revealed that the staff would tell the Maintenance Supervisor about when they found a problem and he always instructed them to log the problem into the TEL's system. LVN A further stated that she was unaware of the broken handle in the shower room, or the broken windowpanes in the dining room. Interview on 01/11/24 at 9:49 AM, the Maintenance Supervisor revealed that the facility mandated the use of the TEL's system to report maintenance problems in the facility. The Maintenance Supervisor stated that the nursing staff were required to put information about maintenance issues in the TEL's system all the CNAs and Med Aides had access to the TEL's system and that the staff may not be reporting all maintenance issues in the TEL's system. The Maintenance Supervisor further stated that he was aware of the windowpanes in the dining room but had no reports about the shower handle in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676253 If continuation sheet Page 7 of 8 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 01/11/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some shower room or the gummy build up on the floors at the entrances to the 300 and 400 halls. The Maintenance Supervisor was aware of the ceiling issue near room [ROOM NUMBER] but just had not gotten to fix it. He did not indicate how long he was aware of these issues. Interview on 01/11/24 at 12:36 PM, the DON revealed that having outstanding maintenance issues in the facility could have an ill effect on the residents' sense of wellbeing and that the staff would be re-instructed to be better report maintenance issues in the TEL's system. Interview on 01/11/24 at 1:27 PM, the Administrator revealed that the facility had no policy and procedure for physical environment. He stated they used TELs for guidance on repairs and communication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676253 If continuation sheet Page 8 of 8