Health inspection·October 5, 2023

F 0693 Level of Harm - Minimal harm or potential for actual harm hydration status aeb weight stable, no s/sx of malnutrition or dehydration through review date. Is dependent with tube feeding and water flushes. See MD orders for current feeding orders. Monitor/document/report to MD PRN: Aspiration- fever, SOB, Tube dislodged, Infection at tube site, Self-extubation, Tube dysfunction or malfunction, Abnormal breath/lung sounds, Abnormal lab values, Abdominal pain, distension, tenderness, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, Dehydration. Residents Affected - Few Review of physician orders for Resident #1 dated 09/22/23 reflected the following: Enteral Feed Orderevery shift Infuse 20 ml/hr full strength and increase 20 ml/hr every 8 hours to goal of 60 ml/hr. Review of a facility self-reported incident in the state agency intake database dated 09/26/23 reflected the following: Date/Time you first learned of incident: 9/25/23 Date/Time the incident occurred: 9/23/23 Brief narrative summary of the reportable incident: (Resident #1) admitted to the facility on [DATE] with order to receive Jevity 1.2 at 20 ml / hour and to increase by 20 ml / hour until 60 ml if tolerated. The rate was not increased beyond 20 ml until 9/25. During an interview on 10/05/23 at 11:40 AM, LVN A stated she entered the enteral formula orders from the hospital for Resident #1 but did not trigger it to change every eight hours to increase the amount. LVN A stated the mistake was discovered on 09/25/23 when the family noticed the feeding pump was still set on 20 ml, and they were very upset. LVN A stated the order was corrected immediately, and she did not think there were any harmful effects to Resident #1. LVN A stated she was written up for the oversight, and rightly so. She stated she was responsible for entering orders for residents who admitted on to the hall where she was a charge nurse, and she had been a nurse for a long time, but she was capable of making mistakes, and she had made one in this case. LVN A stated possible negative outcomes to residents as a result of this mistake were weight loss, hunger, and rehospitalization. During an interview on 10/05/23 at 01:50 PM, the DON stated her understanding of what had occurred with Resident #1's order for enteral feeding was LVN A had entered the order in for the tube feeding to be titrated (gradually increased over intervals of time) by 20 mls but did not enter a time for the first and second titration levels, so no one was prompted to change the amount of formula being administered. The DON stated after this was discovered, they notified the physician, ADON, and dietitian to let them know. The DON stated the physician ordered the formula be increased right away to 40 ml/hr, and then the physician came in on 09/25/23 and saw Resident #1 and increased to 60, which was the goal. The DON stated the family called it to the attention of the nurse on duty that day, and the nurse reported to the DON and ADM, who apologized to the family for the concern and submitted a self-report to the State Agency. The DON stated they started g-tube audits and in-servicing all staff, and she (the DON) was responsible for those efforts. The DON stated all the staff and every licensed nurse were re-educated before they came on duty. The DON stated she stayed till 11:00 PM on 09/25/23 making sure everyone had been checked off for g-tube skills. She stated all the nurses were re-educated on adding a time that titration was done. She stated she made sure all formula and feedings were going correctly at the right time for the three additional residents in the facility with g-tubes on 09/25/23, she reviewed the medication log, and reviewed all care plans. The DON stated a potential negative outcome of not receiving the full amount of enteral formula ordered was a resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676421 If continuation sheet Page 2 of 5 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 676421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation - Waxaha 151 Country Meadows Boulevard Waxahachie, TX 75165 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 0693 could have weight loss and signs of dehydration. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/05/23 at 03:12 PM, the ADM stated when Resident #1 was admitted to the facility on [DATE], he was readmitted with a g-tube in place that he had not had before. The ADM stated the formula should have been increased early Saturday morning 09/23/23, but it was not, due to the order not having a time for the titration to a higher amount of formula entered. The ADM stated the error was discovered and corrected Monday 09/26/23, and the dietitian and physician were notified. The ADM stated they began corrective action that day, and all staff were in-serviced, residents with g-tubes reviewed, and the incident was reported to the State Agency and added to the facility's QAPI program. The ADM stated the people responsible for ensuring mistakes like these did not occur were the charge nurse, the ADON, and the DON. The ADM stated the safety net for that oversight was with the facility physician. The ADM stated Resident #1 was seen by the physician on 09/22/23 and 09/25/23, and there were no adverse effects noted. The ADM stated a possible negative outcome of the failure could have been unwanted weight loss, and Resident #1 did lose a small amount of weight over the weekend when the orders were titrated up correctly, but the amount of loss was insignificant. The ADM provided a binder with documents related to the facility's corrective action. Residents Affected - Few Review of physician orders for Resident #1 dated 09/25/23 10:37 AM reflected the following: Enteral Feed Order every day and night shift FORMULA: Jevity 1.2 AT 60 ML/HR X 24 TO PROVIDE _ CC/CAL./DAY FEEDING PUMP TO RUN Continuously. Review of progress notes for Resident #1 dated 09/25/23 at 10:52 AM reflected the following: Np in the building and gave new order for stat cbc, bmp and orthostatic vs, SN recorded BP as followed: 103/75, 102/69 and 100/71. Patient denies any dizziness at this time. Review of a physician progress note for Resident #1 dated 09/25/23 at 03:20 PM reflected the following: Patient denies concerns, has tube feeds running, denies abdomen pain/fullness, plan to increase feeds as tolerated per nutrition and orders written. Review of progress notes for Resident #1 dated 09/26/23 reflected the following note documented by the ADM: The administrator met EMS staff outside the resident's room and asked what was going on. EMS reports that the resident's family called 911 stating the resident was having chest pains, however, when EMS asked the resident, he reported that no pain was occurring. Vital signs were WNL per EMS. The resident was transferred to (hospital) per the family's request. Physician notified. Review of CBC/BMP/UA lab results for Resident #1 from a sample taken 09/25/23 reflected no abnormal results. During an interview on 10/05/23 at 02:57 PM, the ESD sergeant for the EMTs who responded to Resident #1 at the facility on 09/26/23 stated the EMTs noted Resident #1 made no complaints of pain or distress, but the family wanted him transported to the hospital, and Resident #1 agreed to be transported. A copy of the EMT report was requested to be sent via email but not received as of 10/12/23. Review of hospital admission H&P dated 09/26/23 reflected that Resident #1 was seen at the emergency department for concern of chest pains reported by family but no new diagnosis was noted. His weight was marked as 141 lbs. (indicating a 4 lb. loss from the admission MDS; 2.75% (or not significant) loss of weight. Lab results reflected no dehydration or sodium/potassium imbalance. Review of facility in-services from July 2023 through October 2023 reflected the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676421 If continuation sheet Page 3 of 5 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 676421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation - Waxaha 151 Country Meadows Boulevard Waxahachie, TX 75165 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 0693 Abuse, and neglect 09/25/23 and 09/29/23 Level of Harm - Minimal harm or potential for actual harm Customer service 09/25/23 and 09/29/23 G-tube placement, care, orders, and positioning 09/25/23 and 09/28/23 Residents Affected - Few G-tube administration and care 09/25/23 and 09/28/23 Review of a Counseling/Disciplinary Notice for LVN A dated and signed by LVN A on 09/26/23 reflected the following: Employee failed to place order in system correctly to titrate up. Employee must follow physician orders as prescribed. Employee must schedule titration orders in system correctly. Review of skills checklists conducted for all licensed nurses employed by the facility between 09/26/23 and 10/02/23 reflected each nurse successfully completed skills checks for tube feeding and medication administration by tube. Review of a fishbone-style root cause analysis conducted on 09/25/23 reflected the following: G-tube feedings were not given appropriately. Why does this occur? The hospital d/c order was not followed appropriately after admit. Why is that? 1. Admitting nurse added order appropriately but did not trigger time for next nurse to be prompted. Why is that? 2. The nurse thought the way it was worded and entered was sufficient for oncoming nurses. Why is that? 3. Order and MAR that was entered still sent to increase feeding Q8 hours, but got overlooked. Why is that? 4. Additional training and competencies were needed for nurses to understand and follow g-tube orders, g-tube care and flushes, and medication administration, and trigger times for orders to prevent future complications. Review of a Quality Improvement Team (QIT) Tracking Form dated 09/26/23 and ongoing reflected the following: Problem- nurse failed to increase tube feeding per physician orders. Interventions- 1. G-tube competency for all nurses. 2. G-tube orders reviewed for all residents tube feeding. 3. In-service education regarding following physician orders. 4. All residents with G-tube plan of care reviewed. 5. DON/designee to monitor G-tube orders/and perform verification. 6. Abuse/neglect training with all staff. Observation on 10/05/23 between 08:04 AM and 10:26 AM of the two residents in the facility with feeding tubes reflected both were receiving nutrition according to physician orders, g-tube placement was correct, and no distress or other issues were noted. Neither resident was able or willing to participate in an interview. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676421 If continuation sheet Page 4 of 5 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 676421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation - Waxaha 151 Country Meadows Boulevard Waxahachie, TX 75165 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 0693 Level of Harm - Minimal harm or potential for actual harm Review of care plans and MARs for both residents with g-tubes in the facility on 10/05/23 reflected the residents were care planned for enteral feeding and g-tube care and all ordered checks were documented. During interviews on 10/05/23 between 11:12 AM and 3:00 PM, three LVNs, two medication aides, two speech therapists, and one registered nurse reported they had been in-serviced on the above material. Residents Affected - Few Review of undated policy titled Gastrostomy Tube Care and Management reflected the following: It is the policy of this facility to provide proper care and maintenance of gastrostomy tubes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676421 If continuation sheet Page 5 of 5