Health inspection·July 1, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm was observed outside of Resident #1's room secured via Velcro to each end of the door. Resident #1 was observed near the nurses' station located in the hall next to his room in his wheelchair. CNA D stated that she believed it was the family who requested the stop sign banner to prevent Resident #1 from going to his room as a fall precaution. She stated they would have the banner up to redirect him when there was nobody available to sit in his room with him to ensure he didn't get hurt. Residents Affected - Few An interview on 06/29/24 at 01:09 PM with the ADM she stated the banner was requested by the family and hospice as a joint effort in developing interventions that would redirect Resident #1 from going into the room and having a fall. An interview on 06/29/24 at 04:53 PM with RN B she stated the banner was implemented 03/14/24 and it was developed by the IDT in response to the residents' frequent falls as an intervention to redirect him. RN B stated that Resident #1 had a habit of returning to his room after meal services and attempting to transfer himself which he was not able to do resulting in frequent falls. RN B stated Resident #1 was still able to knock down the sign with his hand, but they hoped it would delay him enough to get a staff members attention to assist him or just redirect him to an area where staff were present. RN B said that she understands the resident has a right to fall but they were doing everything they can to prevent those falls because some have led to abrasions and bumps on the head. RN B stated Resident #1 was confused at times and has what is called terminal restlessness (a set of symptoms that occurs at the end of a person's life such as agitation, confusion, and unusual behaviors) which causes him to try to get up and move around when he is unable to on his own. An interview on 07/01/24 at 02:28 PM with the DON she stated she did not see that the care plan was updated after the IDT meeting where it was implemented 03/14/24. She stated it would have been nursing (DON/ADON) to ensure it got updated. The DON stated she did not see a potential negative outcome of not having it in the care plan because staff have been trained on the proper way to use it. The DON stated the order entered into the system was vague and did not specify when to use it, it only said may have- she then stated it should have been in the care plan. An interview on 07/01/24 at 03:03 PM with RN C she stated care plans were used in everything she does on a daily basis. RN C said care plans were used to know the residents individualized care and goals. RN C said care plans were 100% important to giving the resident optimum care. She stated it was important to have updated information on the care plans so that they knew how to care for the residents' current needs. An interview on 07/01/24 at 03:08 PM with the ADM she stated it was her expectation that care plans were updated quarterly and as needed when assessments show there is change. The ADM stated care plans were important because care staff use it to know how to care for a resident. She stated if someone came in from the outside they would need to know how to care for the residents and the care plans are that guide. Review of the facility Care Planning policy last revised 07/2020 revealed: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident. The residents plan of care- focus, goals, and interventions- are communicated and implemented by (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 07/01/2024 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 0656 the members of the health care continuum accordingly. Level of Harm - Minimal harm or potential for actual harm - Residents Affected - Few The residents plan of care is reviewed and revised on an ongoing basis, quarterly at minimum and/ or as needed with changes of condition. 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 07/01/2024 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for residents for 1 of 5 (Resident #1) residents reviewed for environment. Residents Affected - Few The facility failed to keep Resident #1's room clean and free of bed bugs. This was determined to be past non-compliance at potential for more than minimal harm due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the inspection. This failure could place the residents at risk of unsanitary and uncomfortable conditions. Findings include: Review of Resident #1's face sheet dated 06/30/24 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of unspecified atrial fibrillation (abnormal heart rhythm), cognitive communication deficit (a problem with one or more cognitive skills involved in communication, such as attention, memory, or reasoning), dysphagia-oropharyngeal phase (difficulty in swallowing food or liquid), schizophrenia-unspecified (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior), unsteadiness on feet, unspecified anxiety disorder (fear characterized by behavioral disturbances), and unspecified hyperlipidemia (high cholesterol). Review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 08 indicating moderate cognitive impairment. The MDS assessment also revealed the resident was on hospice care. Review of Resident #1's nursing progress note dated 06/24/24 revealed, Insect reported in resident's room on end of bed. Resident in the hall in his wheelchair with sitter at side. This nurse went to room to assess. Insect at the foot of bed and appeared to be dead AEB no movement upon touching and disposing. Resident transitioned from 200 hall and placed in room [ROOM NUMBER] with new bedding. Body assessed with no signs of bites or skin alterations. Maintenance informed of insect in room and notified exterminator for assessment in the am. Maintenance provided resident with temporary air mattress in new room until hospice is able to replace air mattress in room tomorrow. Resident given pain medication and PRN anxiety medications to assist with back pain, change in mattress and anxiety with being in new environment. Bed is in lowest position, call light in reach, fall mats in place, and hydration provided. Sitter remains at bedside. Nursing to monitor frequently for comfort. Nursing to continue skin assessments throughout follow-up. Spoke with resident's [family member]to give update. [family member] reports that she has updated resident's [family member]. NP at facility and informed with no concerns at this time. Review of facility pest sighting services log dated 06/24/24 revealed bed bugs, [Resident #1's room]. Review of pest service inspection report dated 06/24/24 revealed tech comments: treated room [Resident #1's room] for bed bugs, live activity found. It also revealed 1 gallon of product was applied to treat the room for target pests: bed bugs. (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 07/01/2024 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 0925 Review of Resident #1's skin assessment dated [DATE] revealed, no open skin areas. Level of Harm - Minimal harm or potential for actual harm Review of Resident #1's skin assessment dated [DATE] revealed, resident noted skin warm, dry, and intact. Skin turgor appropriate for age. No signs of bites, redness or swelling noted. Residents Affected - Few An interview on 06/29/24 at 12:21 PM with Resident #1's family member stated she was first made aware of the bed bugs in Resident #1's room by the hired agency sitter 06/24/24. The Family member stated that the agency sitter took a picture of the bed bug that was on the bed while she was getting Resident #1 ready for bed. She stated the facility removed him from the room and then relocated him back after treatment of the room. An interview on 06/29/24 at 12:45 PM with the agency sitter, she stated that she saw the bed bug on Resident #1's bed on 06/24/24 and she took a picture of it and sent it to the family member. The agency sitter stated she did not see any others and did not see any noticeable bites. An interview on 06/29/24 at 04:53 PM with RN B with the hospice agency, she stated she was notified by Resident #1's family member on 06/24/24 about bed bugs in Resident #1's room. RN B stated when she tried to question the ADM about the bed bug concerns the ADM would neither confirm or deny there was bed bugs. RN B stated a potential negative outcome to bed bug bites was uncomfortable itching, allergic reaction, or secondary skin infection. RN B did not note any bite marks on Resident #1. An interview on 06/30/24 at 12:50 PM with the pest services technician he stated aside from Resident #1, there was an inspection done in another room which was negative for activity, he stated he also inspected the nurse's station, the lobby, and common areas were residents congregate and there was no evidence of additional bed bugs in those areas. The Pest services technician stated he did find live activity in Resident #1's room and they treated the area and cleared the bugs and removed/ disposed of the mattress. He stated that protocol was followed, and they treated the room where live activity was found but are unable to apply additional treatment through other rooms/ halls without evidence that they have spread. He stated that to his knowledge it appeared to have been confined to Resident #1s room. He stated bed bugs were hitchhikers and were carried by people and their items. He stated an additional inspection was performed 06/29/24 in Resident #1's room and it was negative for bedbugs, so he believed treatment was effective. An interview on 06/30/24 at 01:30 PM with MD E, (Resident #1's physician and facility medical director) he stated that the facility was timely in notifying them of Resident #1s exposure to bed bugs. He stated it was his expectation that staff notify him or his proxy (NP) when things like this occur. He said on 06/24/24 the NP was in the building so the facility was able to make the report to her. He stated a potential negative outcome to bed bug bites would be the potential for discomfort and infection he said, skin integrity becomes the issue. MD E said he expects that the facility would have followed their pest control policy and did not believe there was a negative outcome to Resident #1 from this exposure. An interview on 06/30/24 at 02:43 PM with Hospice ADM, she stated that on skin assessments completed by the hospice LVN and notes in the hospice shower aides from 06/25/24 through 06/27/24 there were no abnormal findings on Resident #1's skin such as bite marks noted. An observation on 07/01/24 at 12:30 PM nurse surveyor, conducted observations of 5 resident rooms on Resident #1's hall that included Resident #1. The five rooms examined were negative for pest activity at the time of the investigation. Skin assessments completed by nurse surveyor did not reveal (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 07/01/2024 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 0925 any healing spots to confirm bed bug bites. Level of Harm - Minimal harm or potential for actual harm An interview on 07/01/24 at 02:28 PM with the DON she stated after the bed bug was found they completed a skin assessment on 06/25/24 which was negative for bite marks. The DON stated that in the last month and a half Resident #1 has had 7 different agency sitters which makes it difficult to determine how or who brought the bed bugs in. The DON said that they followed the policy and removed Resident #1 from the room in order to shower him and assess, and they called pest control to treat the room and inspect other areas of the facility. The DON said skin assessments were completed on all the other residents and no bite marks were observed or bugs noted in the rooms. Residents Affected - Few An interview on 07/01/24 at 03:08 PM with the ADM she stated she did not know how many bed bugs were found in Resident #1's room she just knows there was one seen on the curtain and one on the bed. The ADM said she believes they followed their policy which was to remove the resident and assess him and other residents and treat the area where live activity was found. The ADM said the room was deep cleaned and linens and items were bagged separately and washed and dried separately. The ADM said they did attempt a root cause analysis to determine where this came from but were unsuccessful because Resident #1 has had 6 to 7 sitters and there had been a lot of traffic to his room. She stated the sitters that do come will sometimes bring bags with a blanket or other items while they are here caring for the resident. The ADM stated she has reached out to the agency and let them know she wants consistency with the sitters being sent over that way they can limit exposure to those items. The ADM stated assessments to Resident #1 and other residents revealed no bites or negative outcomes and she believes it was contained to Resident #1's room. Review of facility Pest Control policy last revised 05/2020 revealed: It is the policy of this facility to utilize pesticides and rodenticides in a safe an efficient manner to control pests with the least amount of contamination to the environment. Responsibilities: Facility staff will: l. Report any pest sightings to supervisor. 2. Advise staff on preventive measure and the steps needed to ensure safety. Differs case by case. This includes room changes, isolation, or any other preventative measures. 3. Secure services of a Pest Control company for routine and PRN services to control pests with the least amount of contamination to the environment. Pest Identification: The following guidelines for pest identification: 1. (continued on next page) 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 07/01/2024 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 0925 When pests are sighted, determine why the infestation is occurring and advise department on preventive measures Level of Harm - Minimal harm or potential for actual harm 2. Residents Affected - Few Use pesticides only after all other channels of control are exhausted 3. Use pesticides only as a preventive measure and in conjunction with proper mechanical controls 4. Report insect or pest sightings to the housekeeping/maintenance supervisor immediately. Include the following information: a. Type of problem b. Location Pest Prevention: The following are guidelines for pest prevention: 1. All storage and food preparation areas are to be kept clean. This includes walls, floors, shelving, cabinet tops, sinks, equipment, etc. 2. Keep grounds free of trash and brush. 3. Keep the dumpster area clean. 4. Food stored in resident rooms will be in covered containers. 5. Clean up food spills. (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 07/01/2024 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 0925 6. Level of Harm - Minimal harm or potential for actual harm Screen foundation areas with mesh. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676253 If continuation sheet Page 8 of 8