Health inspection·February 27, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one of four residents (Resident #20) reviewed for resident rights. The facility failed to ensure CNA A did not stand over Resident #20 while assisting the resident with her meal in her room on 02/26/2025. This failure could place residents at risk of feeling rushed to eat or not interested in eating, which could result in weight loss and decreased psycho-social well-being of anguish or frustration. The findings included: Record review of Resident #20's MDS Assessment, dated 01/31/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #20 had a staff assessment BIMS score of 06, which indicated the resident was severely impaired. She had partial to moderate assist with eating and active diagnoses which included: Dementia (confusion), malnutrition (not nourished), anxiety disorder (nervous), and muscles weakness. She had a mechanically altered and therapeutic diet and no issues with swallowing food and drinks. Record review of Resident #20's Care Plan, dated 01/08/2025 and revised, revealed, The resident has potential nutritional problem r/t GERD (gastrointestinal reflux disease) , dementia, hypokalemia (high potassium): Goals - The resident will maintain adequate nutritional status as evidenced by maintaining weight with no S/Sx of malnutrition through review date: 01/08/2025 and intervention: Eating - The resident requires set up assist of (1) staff for eating. Observation on 02/26/2025 at 8:40 a.m. in Resident #20's room revealed CNA A was standing at the bedside next to Resident #20 who was lying in the bed . There was 90% of Resident #20's breakfast on her plate and CNA A had a spoon in her hand with food on it. CNA A lifted the food and was telling Resident #20 she needed to eat her food and to try and take just a few more bites. Resident #20 said she would try but was not really hungry. Observation and interview on 02/26/2025 at 12:30 p.m. in Resident #20's room revealed CNA A was standing at the bedside next to Resident #20 who was lying in the bed . There was 75% of Resident #20's lunch on her plate and CNA A stated to the State Surveyor she was going to try and get her to at least take a couple of more bites of her lunch. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 676253 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 02/27/2025 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)