Health inspection·January 23, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #1's physicians orders reflected an order for Nystatin powder,100000 unit/GM, apply topically to groin area two times per day for rash, with a start date of 1/14/2024 at 5pm and an end date of 1/17/2024. Review of Resident #1's physician's orders reflected an order for Nystatin powder, 100000 unit/GM, apply topically to groin area two times per day for rash, with a start date of 1/17/2024 at 9 am an end date of 1/31/2024. Review of Resident #1's facility weekly skin assessment dated [DATE] at 3:05 pm, reflected Skin intact, no redness or open areas noted. Review of Resident #1's PRN skin assessment dated [DATE] at 8:41 am, reflected Resident #1 had Groin Rash - redness to groin area. Review of Resident #1's nursing progress notes reflected a late entry with an effective date of 1/17/2024 at 8:45 am but charted on 1/18/2024 at 10:53 am. The investigator entered the facility on 1/18/2024 at 10:09 am. This late note by LVN B, reflected: CNA informed nurse that resident had new reddened area to sacrum; barrier cream ordered after every incontinent episode. Daughter notified. Further review progress notes reflected no entries on 1/14/24, 1/15/24 or 1/16/24, 1/17/2024 that FM had been notified of skin assessment on 1/14/2024. Review of Resident #1's hospital records dated 1/18/2024 reflected on 1/17/2024 Resident #1 was admitted and diagnosed with cellulitis (bacterial skin infection) in his scrotal/perineal area and wound pictures were taken for the record. Wound notes stated: wound bed cover: cherry; wound notes: Scrotum red and painful. During an interview on 1/19/2024 at 9:48 am, Resident #1's FM F stated Resident #1 went to the (ER) emergency room on 1/17/2024 and once there, he was diagnosed with cellulitis in his perineal area. FM F stated no one from the facility had called them to let them know Resident #1 was having any skin issues on 1/14/2024. FM F stated they were typically at the facility every day but had not gone to the facility on 1/14/2024 and 1/15/2024 because they had been feeling ill. FM F stated when they returned to the facility on 1/16/2024 in the evening, FM F was informed of the skin breakdown, but that staff had downplayed it, so they didn't think it was serious. FM F stated when Resident #1 was admitted to the hospital the following morning on 1/17/2024, he was diagnosed with cellulitis of his perineal area, and FM was shocked at how bad the perineal area looked. FM F stated they had no idea it was that red and that bad looking. FM F started crying and was upset that the facility had not told them earlier about the skin issue, FM F stated if I had known, I would have stayed on top of it and made sure it was taken care of. During an interview and record review on 1/23/2024 at 10:06 am, LVN B stated she worked 6 am to 6 pm on 1/14/2024 and the aide came to her and told her Resident #1's catheter was leaking. She stated she went to check on it and noticed the redness in his perineal area. She stated the catheter was not leaking at that time, but the skin was reddened but not excoriated. She stated she contacted the provider for an order for Nystatin powder and they started applying it that evening. She stated the FM was in the building on Sunday, 1/14/203 and she spoke to her in person and told her about the skin breakdown. She stated she thought she had put in a progress note. When this investigator showed LVN B Resident #1's progress notes indicating there was no progress note about the skin breakdown on 1/14/24, 1/15/24, 1/16/24, or 1/17/24, she stated she thought she spoke to the FM on 1/14/2024 and put in a progress note. LVN B stated she put a late progress note in on 1/18/2024 for 1/17/2024 because (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676421 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 676421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with all the commotion in the building on the 17th and the resident going to the hospital, she forgot to put in a progress note. She stated she did not know the state investigator was in the building at the time she put in her late note on 1/18/2024. During another interview on 1/23/2024 at 1:20 pm, LVN B stated she was pretty sure she spoke to FM F on 1/14/24 about the skin issue because there was an issue with the window in Resident #1's room and she thought it was the same day. She confirmed that she had not documented on a progress note that she had spoken to FM F about the perineal skin issue noticed on 1/14/2024. Review of undated facility policy Nursing Administration, Section Resident Rights reflected The resident has the right: 11. To choose a personal attending physician (and be informed how to contact him or her), to be fully informed in advance about care and treatment , and, unless adjudicated incompetent or other found in capacitated under state late participate in planning medical treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676421 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 676421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing forfor one (1) (Resident #1) of 10 residents reviewed for pressure wounds, in that: Residents Affected - Few The facility failed to ensure that CNA D reported a pink area on Resident #1's left buttock to the nurse for further assessment. This failure placed residents at risk of improper wound management, the development of new pressure injuries, deterioration in existing pressure injuries, infection, and pain. Findings included: Review of Resident #1's face sheet dated 1/18/2024 reflected an admission date of 8/18/2023 with diagnoses that included left Femur fracture, Cognitive communication deficit, age related cognitive decline, Type 2 Diabetes, Heart Disease, Benign Prostatic Hyperplasia (BPH), Hypertension, lack of coordination, reduced mobility and need for assistance with personal care. Further review reflected Emergency contact #1 and Financial Responsible Party was FM F. Review of Resident #1's quarterly MDS assessment dated [DATE], section C500 for BIMS summary score reflected a dash (-) (indicating it had not been completed). Review of section C for staff assessment of memory problems; C600, C700 and C800 reflected dashes. Review of Resident #1's quarterly MDS assessment dated [DATE], section C500 for BIMS summary score reflected a dash. Review of section C for staff assessment of memory problems; C600, C700 and C800 reflected dashes. Review of Resident #1's quarterly MDS assessment dated [DATE], section C500 for BIMS summary score was blank. Review of section C for staff assessment of memory problems; C600, C700, C800 were blank. Review of Resident #1's quarterly MDS dated [DATE] in section C500 for BIMS summary score was blank. Review of section C for staff assessment of memory problems; C600 indicated Resident had a memory problem and section C700 reflected Resident #1's cognitive skills for decision making were severely impaired. Review of Resident #1's care plan last revised 8/31/2023 reflected the problem: Has pressure ulcer or potential for pressure ulcer development r/t UNSPECIFIED TROCHANTER FRACTURE OF HE LEFT FEMUR, MILD PROTEIN CALORIE MALNUTIRION, AND IMPAIRED MOBILITY; with interventions: Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care; Out of bed unless contraindicated, Use lifting device, draw sheet, etc. to reduce friction, Weekly head to toe skin at risk assessment. Review of Resident #1's physicians orders reflected an order for Nystatin powder,100000 unit/GM, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676421 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 676421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few apply topically to groin area two times per day for rash, with a start date of 1/14/2024 at 5pm and an end date of 1/17/2024. Review of Resident #1's physician's orders reflected an order for Nystatin powder, 100000 unit/GM, apply topically to groin area two times per day for rash, with a start date of 1/17/2024 at 9 am an end date of 1/31/2024. Review of Resident #1's facility weekly skin assessment dated [DATE] at 3:05 pm, reflected Resident #1 had Skin intact, no redness or open areas noted. Review of Resident #1's PRN skin assessment dated [DATE] at 8:41 am, reflected Resident #1 had Groin Rash - redness to groin area. Review of Resident #1's shower sheet dated 1/15/2024 and filled out by CNA C, reflected no bruises, skin tears, red areas, open areas, rashes. Review of Resident #1's bathing tasks in EMR reflected Resident #1 received a bath on 1/15/2024 and 1/17/2024. A shower sheet for this task on 1/17/2024 was requested and not provided by time of exit. The tasks were entered by CNA C. Review of Resident #1's hospital records dated 1/18/2024 reflected Resident #1 was admitted on [DATE] and diagnosed with pressure injury to the left buttock area that was present upon admission to the ER (emergency room). Wound pictures taken at 10:26 am were provided in the record with measurements of wound length - 7cm, wound width - 7 cm, wound surface 49 cm squared. Wound bed color: purple, cherry, pink, non-blanching, Resident was also diagnosed with cellulitis (bacterial skin infection) in his scrotal/perineal area and wound pictures were taken for the record. Wound notes stated: wound bed cover: cherry; wound notes: Scrotum red and painful. During an interview on 1/19/2024 at 9:48 am, FM F stated Resident #1 went to the ER on [DATE] and once there he was diagnosed with a pressure injury on his backside and cellulitis in his perineal area. The FM F stated no one from the facility had called them to let them know Resident #1 was having any skin issues on 1/14/2024 and the facility never said anything about a pressure injury. FM F stated they were typically at the facility every day but had not gone to the facility on 1/14/2024 and 1/15/2024 because they had been feeling ill. FM Fstated when they returned to the facility on 1/16/2024 in the evening, FM F was informed of the skin breakdown in the perineal area, but that staff had downplayed it, so they didn't think it was serious. FM F stated no one said anything to her about Resident #1 having a pressure injury, reddened area or any skin issues with his backside. FM Fstated when Resident #1 arrived at the hospital, they were shocked at how bad the pressure injury and perineal area looked. FM F stated they had no idea that the perineal area and left buttock looked that bad. FM F started crying and was upset that the facility had not told them earlier about the pressure injury and skin issue. FM F stated the facility never said anything to them about a pressure injury on Resident #1's left buttock, the first she heard and saw of it was when he was in the ER on [DATE]. FM F stated she was in the facility before Resident #1 was sent to the ER and she did not remember staff changing or bathing resident. She stated when Resident #1 got to the ER his catheter had been leaking and his brief was saturated. During an interview on 1/19/2024 at 3:01 pm, CNA D stated she had worked on 1/16/2024 on the 2 pm to 10 pm shift and had provided incontinent care for Resident #1. She stated she did not notice any open skin areas on her shift but there was a little redness to his perineal area and a pink area on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676421 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 676421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few his left buttock that she put some barrier cream on. She stated when a resident has skin breakdown they are supposed to tell the nurse, but since the buttock area was just a little pink, she just put barrier cream on it. She stated she did not mention it to the nurse because there was no open areas or skin breakdown. During an interview on 1/19/2024 at 3:50 pm, CNA E stated she had worked the 10 pm to 6 am shift on 1/16/2024 to 1/17/2024. She stated she had provided incontinent care to Resident # 1 during the night and his peri area was red and the Resident would make noises when they cleaned that area. She stated, it had gotten to the point where he didn't want us to touch the area and it appeared very sensitive. She stated she remembered telling a nurse about this, but she did not remember which nurse it was. She stated when a resident has reddened areas, she would put barrier cream on it for them. She stated she does not remember if Resident #1's backside was red or not, but she did remember putting barrier cream in his scrotal area. During an interview on 1/19/2024 at 3:27 pm, CNA C stated she had worked on 1/15/24 and 1/17/24 and had provided care to Resident #1. She stated she had bathed Resident #1 on 1/15/2024 and had not noticed any skin breakdown. On the morning on 1/17/2024, LVN B told her Resident was going to be going to the hospital, so she cleaned Resident #1 up and gave him a bed bath. She stated there was no open skin areas. She stated resident was red in his perineal area, but she did not remember if there was any pink or red areas on his left buttock. She put barrier cream on the perineal area and told LVN B about it. During an interview on 1/23/2024 at 10:06 am, LVN B stated she had been working the 6 am to 6 pm shift on 1/17/2024. She stated Resident #1's FM F came in to visit and requested he be sent to the ER for evaluation. She stated CNA C was cleaning Resident #1 up before going to the hospital and told her about his peri area being red again. When CNA C was finished she went in and put Nystatin powder on Resident #1's perineal area. She stated it was still reddened in the perineal area, but the skin was intact. She stated she did not remember observing any other skin issues on Resident #1's back or buttock area but could not remember if she had looked or not. A facility policy on Quality of Care, Skin Management System, revised 12/2019 reflected: Policy: It is the policy of this facility that any resident who enters the facility without pressure ulcers will have appropriate preventive measures taken to ensure that the resident does not develop pressure ulcers, or that residents admitted with wounds will not develop signs and symptoms of infection, unless the resident's clinical condition makes the development unavoidable. 3. A plan of care will also be initiated to address areas of actual skin breakdown. The plan of care will be reviewed and revised as needed. 4. Residents will have ongoing head to toe assessment done weekly, incorporated into the LN Weekly Summary review by the licensed nursing staff. 5. CNA's will complete a Body Shower Check Sheet daily on every resident and turn it in to the charge nurse for possible follow up of any new skin concerns. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676421 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 676421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals were stored in locked compartments and inaccessible to unauthorized staff, visitors, and residents for one of one (MC 1) overflow medication carts reviewed for medication storage. The overflow medication cart (MC 1) on the 400 hallway, was observed to be unattended and unlocked. This failure could place residents, unauthorized staff and visitors at risk for drug diversion and access to medications that could cause physical harm, permanent injury or even death. Findings include: Observation on 1/23/2024 at 10:46 am revealed MC 1 on the 400 hall was unattended and unlocked. Observation on 1/23/2024 at 10:46 am revealed there were two residents sitting at a table in the common area right off the 400 hall near the unlocked MC 1. Observation on 1/23/2024 at 10:49 am revealed two facility therapy staff walked by the unlocked MC 1. Observation on 1/23/2024 at 10:50 am revealed a facility CNA walked by the unlocked MC 1. Observation on 1/23/2024 at 10:52 am revealed the DON walked up to the unlocked, unattended MC 1 and locked it. During an interview on1/23/2024 at 10:52 am, the DON stated she had gone up and locked the medication cart because she had noticed it was unlocked. She stated she did not have a key to reopen the cart. She stated medication carts were not supposed to be unlocked while unattended. She stated the medication cart was an overflow medication cart and the Medication Aide (MA) was responsible for the cart. She stated anyone that walked by could have gotten in the cart and possibly harmed themselves by taking medications that were not theirs or even committed a drug diversion. During an interview on 1/23/2024 at 10:55 am, MA-A stated she was the staff responsible for the overflow medication cart and had a key to the cart. MA-A stated she had received training on medication carts, and it was supposed to be locked. She stated if a cart was left unlocked, a resident or anybody could have gotten in it and anything can happen, they could get sick, have to go to the hospital, they could be allergic. MA-A unlocked the mediation cart and some of the medications observed were blood pressure medications, anti-seizure medications, nerve pain medications, blood sugar medications and medication for heart rhythm problems. During an interview on 1/23/2024 at 11:47 am, the DON stated, all of them know the carts were supposed to be secured and her expectations were that the carts would be locked. She further stated MA-A knows I am going to get on her because I just did an in-service last week on this, and she attended. DON provided a copy of an in-service on medication carts and pointed out and confirmed MA-A signature was on the in-service sheet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676421 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 676421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 1/23/2024 at 12:48 pm, the AD stated her expectation was that med carts are supposed to be locked when staff was not there. She stated carts needed to be locked to protect the residents and visitors from getting into the medications. Record review of facility's in-service sheet dated 1/9/2024, reflected med carts should be locked at all times when you are away from your carts. It ensures the safety of our residents and prevents possible drug diversions. MA-A signature was observed to be on the in-service sheet. Review of undated facility policy Medication Management Process under heading B. Security of Medications received by Community Staff reflected: Medications received by the community staff will be stored in a locked cart or container. Only authorized staff will have access to the medication cart key. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676421 If continuation sheet Page 8 of 8