Health inspection·February 7, 2024

F 0684 Level of Harm - Actual harm Residents Affected - Few Record review of Resident #1's CP indicated a [Focus Area] created 1-18-2024 and evidenced by actual impairment to skin integrity R/T burn to right side hip from soup and treatment was documented. Resident was seen by wound physician on 1-22-2024, 1-29-2024, and 2-5-2024. The [Intervention] initiated on 1-18-2024 was to follow facility protocols for treatment of injury. A second [Focus Area] created 6-2-2023 evidenced by risk of impaired cognitive function/dementia or impaired thought was documented. The [Intervention] created on 6-2-2023 was to give step-by-step instructions one at a time as needed to support cognitive functions and report any changes in cognitive function, specifically in decision making ability, memory, recall, awareness of surroundings and other, difficulty expressing self, difficulty understanding others, sleepiness, or confusion. A third [Focus Area] created 6-2-2023 evidenced by risk of visual function R/T aging was documented. The [Intervention} created 6-2-2023 was to monitor, document and report to the physician any signs of acute eye problems; changes in ability to perform ADLs, decline in mobility, second visual loss, double vision, tunnel vision, blurred vision, or hazy vision. Record review of Resident #1's Progress Notes, dated 1-17-2024 indicated a CNA B was changing the resident when it was observed that resident had a burn with a thick blister to lateral right thigh. Aide alerted nurse. Resident stated that he spilled a container of soup, brought from home, on him last night. Resident stated he did not tell anyone at the time of incident. Wound care performed per NP: cleanse with normal saline, pat dry, apply Silvadene cream, and dress with dry dressing. Record review of Resident #1's Progress Notes, dated 1-17-2024 indicated burn incident to right side hip area. This NP notified today by nurse of incident. Resident reported accidentally hitting bedside table and knocked over soup that was brought to him by family. Assessment of site completed with redness noted to right side hip area, non-tender to touch, denies pain at this time, and able to move extremities with no limitations. Stable at baseline in good spirits with intermittent confusion. Care discussed with nursing, new orders noted for Silvadene cream, and dress with dry dressing. Nursing and wound care to monitor closely for delayed complications. Record review of Resident #1's Progress Notes, dated 1-22-2024 indicated Resident was seen by wound doctor for burn to the right side (flank). Area was cleaned with normal saline and anesthesia was achieved using topical benzocaine. Then with surgical technique, 15 blade was used to surgically excise 21.00 cm of devitalized tissue and necrotic subcutaneous level tissues along with sought and biofilm were removed at a depth of 0.15cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 70% to 35%. Hemostasis was achieved and a clean dressing was applied, Resident has been made aware of the condition of the skin and the treatment that is in place. Record review of Resident #1's Progress Notes, dated 1-29-2024 indicated Resident was seen by wound doctor for burn to the right flank and wound with improvement observed on this visit by evidenced by decreased surface area and decreased necrotic tissue increased granulation. Wound was cleaned with n/sand anesthesia was achieved using topical benzocaine. Then with surgical technique 15 blade was used to surgically excise 12.6cmof devitalized tissue and necrotic subcutaneous level tissues along with slough, and biofilm were removed at a depth of 0.15cm and healthy bleeding tissue was observed. As a result of this procedure the nonviable tissue in the wound bed decreased from 50% to 20%. Hemostasis was achieved and a clean dressing was applied. Resident has been made aware of the condition of burn and the treatment that is in place. Record review of Resident #1's Progress Notes, dated 2-5-2024Resident was seen by wound md for burn to the right flank area with improvement observed on this visit evidenced by decreased surface (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676421 If continuation sheet Page 2 of 14 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 02/07/2024 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 0684 Level of Harm - Actual harm Residents Affected - Few area. Wound was cleaned with normal saline and anesthesia was achieved using topical benzocaine and resident has no complaint of pain or discomfort during this assessment. Then with clean surgical technique, 15 blade was used to surgically excise 9.00cm of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a depth of 0.1cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 30% to 5%. Hemostasis was achieved and a clean dressing was applied. Resident has been made aware of the condition of the wound and the treatment that is in place. Record review of Resident #1's skin evaluation, dated 1-18-2024, reflected a fluid filled blister to the upper right side of the torso area with surrounding skin red in color and blister intact, right lower side of torso area had fluid filled blister with redness to surrounding skin. Record review of Resident #1's skin evaluation, dated 1-23-2024, reflected a burn to the resident's right flank. It was 6 centimeters by 10 centimeters and 1 centimeter deep. Resident would continue to receive wound care on wound rounds. Record review of Resident #1's skin evaluation, dated 1-25-2024, reflected burns to the resident's right side. Record review of Resident #1's skin evaluation, dated 2-1-2024, reflected the resident was being treated for a burn wound to the resident's right side. Record review of Resident #1's skin evaluation, dated 2-5-2024, reflected the resident was being treated for a burn wound to the resident's right side. Record review of Resident #1's Order Summary Report indicated an order, dated 1-29-2024, to clean right flank, pat dry, and apply alginate calcium and collagen powder and cover with gauze island dressing every 24 hours as needed for burn. Record review of Resident #1's Order Summary Report indicated an order, dated 2-6-2024, to clean right flank, pat dry, and apply xeroform and apply gauze island on day shift for burn. Interview and observation on 2-5-2024 at 10:30 AM with Resident #1 revealed Resident #1 was lying in bed relaxing. His tray side table had two thin rectangular non-slip pads. He stated he just got the non-stick pads today, and they were there to help things from slipping off his table. On the evening of 1-16-2024 he asked CNA A to heat up some soup for him. When CNA A [NAME] the soup back, he stated she placed it on the bed side table and left. He sat up in bed and knocked the soup over by accident onto his right-side lower torso area, which caused him to holler out in pain. He gauged the pain on a pain scale of 1-10, with 0 being no pain and 10 being the worst. Resident #1 stated the pain he felt after spilling his soup on his right-side lower torso area was an 8 out of a possible 10. When he called for help after he spilled his soup, he stated CNA A came back to his room, who changed his clothes and his bedding. He did not remember if CNA A asked him if he was in any pain. No other staff member came to his room to look at his skin or to see if he needed medical attention. During the interview, CNA E came to the room and moved back Resident #1's covers to expose his right-side lower torso area. His right-side lower torso area was covered with two light pink bandages. Interview on 2-5-2024 at 11:20 AM with CNA F revealed she had heard Resident #1 spilled soup on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676421 If continuation sheet Page 3 of 14 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 02/07/2024 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 0684 Level of Harm - Actual harm Residents Affected - Few himself on 1-16-2024. If she had been the CNA on duty, she stated she would have wanted to see where the soup was spilled and get the nurse to check for injuries. According to CNA F, CNA A failed in her duties having not reported the spill to the nurse for medical assessment and treatment. Interview on 2-5-2024 at 11:45 AM with CNA B revealed she was in Resident #1's room on the evening of 1-17-2024 to give Resident #1 a bed bath. When she was about to begin, Resident #1 pointed to his right lower torso area, referring to the area he spilled his soup, and asked if she was going to do anything about it, because [it was uncomfortable.] She pulled back Resident #1's covers and clothing to reveal a big bubble blister. She immediately got LVN C for a medical assessment. Both CNA B and LVN C returned to the room where she observed LVN C assess the injury. CNA B observed the big bubble blister was seeping clear liquid. After the wound was dressed by LVN C, CNA B continued with Resident #1's bed bath. If she were on duty the night of 1-16-2024, when Resident #1 spilled his soup, she stated she would have asked the nurse to check his skin. CNA B stated CNA A neglected Resident #1 by not reporting the matter to the nurse for medical assessment and treatment. Interview on 2-5-2024 at 12:40 PM with CNA A revealed Resident #1 asked her to heat up some soup for him on the evening of 1-16-2024. The soup was a single serve microwavable soup. She did what she was asked and returned the soup to Resident #1's bedside table. She stated she placed it on the bed side table and told Resident #1 to wait until it cooled off, because she stated it was steaming. CNA A left the room to address other duties. CNA A guesstimated 5-10 minutes passed when she noticed his call light was activated. After an additional 2-3 minutes, she stated she entered the room for the call. When she entered the room, she learned that Resident #1 had spilled his soup on his right lower torso area. She removed Resident #1's clothing and bedding then provided clean replacements. After, she left the room to address her duties. She did not report the incident of Resident # 1 having spilled soup, which she referred to as steaming on his right lower torso area. Interview on 2-5-2024 at 1:49 PM with LVN C revealed she was on duty the evening of 1-17-2024, around 5:00 PM, when CNA B reported Resident #1 needed medical attention. When LVN C entered the room, she noticed Resident #1's right lower torso area was red. LVN C pulled back the sheet and discovered two blistered areas, one of which one had popped exposing raw skin. She informed the nurse practitioner, applied Silvadene cream, and dressed the wound. LVN C stated Resident #1 told her [it hurt at the time it happened.] LVN C had been a nurse for 17 years with experience treating burns and characterized Resident #1's injury either a 1st degree or a 2nd degree burn. Furthermore, she stated the skin would have continued to burn until the burn stopped on its own, or if something were applied like cold water, ice, or Silvadene cream. Had the burn been treated sooner, it might have had a better outcome. LVN C stated CNA A should have told the nurse after she learned Resident #1 spilled hot soup on himself. Also, neglect did not have to be a willful act. LVN C completed a SBAR form, to note a Change in Condition, for Resident #1's burn on 1-17-2024 at 5:00 PM. The wound care was assigned to the wound care nurse, LVN G, because raw skin was exposed and there was a greater risk of infection. According to WebMD at [https://www.webmd.com/drugs/2/drug-4910silvadene-topical/details] Silvadene cream was a medication used with other treatments to help prevent and treat wound infections in patients with serious burns. Group interview on 2-5-2024 at 2:10 PM with LVN G (wound nurse), Physician H (wound doctor), and Physician I (wound doctor) revealed a consensus that the wound on Resident #1 was classified as a 2nd degree burn. LVN G stated that CNA A should have reported the soup spill to the nurse for a medical assessment. Interview and Observation on 2-6-2024 at 10:25 PM revealed resident # 1 in bed resting comfortably, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676421 If continuation sheet Page 4 of 14 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 02/07/2024 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 0684 Level of Harm - Actual harm alert, and responded to questions appropriately. He recalled the night of 1-16-2024 when he spilled his soup. He stated he was in pain and discomfort after the soup spill, was in continued pain and discomfort throughout the night, and into the next day until he received treatment. He denied current pain and discomfort. Residents Affected - Few Interview on 2-6-2024 at 4:35 PM with the ADON revealed she had been working at the facility for about 1.5 years. She was in charge of the Express Side of the facility that encompassed halls 200, 300, and 400. CNA A was under her supervision. On the evening of 1-16-2024, which was the day Resident #1 spilled his soup, hollered out in pain, and sustained 2nd degree burns to his right lower torso area. CNA A did not report the incident to the nursing staff for a medical assessment. Having heated the soup, delivered it [steaming,] and having told Resident #1 to let it cool, CNA A should have reported the accident to nursing staff after the spill. The failure of Resident #1 not receiving immediate medical care was CNA A did not report the spill to the nurse. The ADON stated that CNA A was trained in the facility's [Change in Condition, Response] policy and that the incident should have been reported to the nurse for a medical assessment and treatment. Interview on 2-6-2024 at 5:00 PM with the DON revealed that CNA A was trained to report all incidents and accidents to the charge nurse for a medical assessment. CNA A failed in her duties when she left the steaming soup in Resident #1's room and failed to inform nursing staff of the accident for a medical assessment and treatment. Interview on 2-6-2024 at 5:30 PM with the ADM revealed Resident #1's soup burn prompted a change in Resident #1's condition and the incident met the criteria for the facility's Change in Condition, Response Policy. CNA A was suspended for a day, while the facility investigated the matter. The ADM stated that CNA A failed in her duties to report the incident to the nurse for a medical assessment and medical treatment. Record review of CNA A's counseling and disciplinary notice, dated 1-18-2024, indicated CNA A was suspended, pending investigation, subject to discharge. Employee knew that a resident spilled hot food on them and failed to notify the charge nurse of the incident / change of condition. Record review or Resistant #1's SBAR Communication form, dated 1-17-2024, indicated Resident#1 had a change in condition, due to a burn, which occurred on 1-16-2024. Record review of the facility's [reporting alleged violations of abuse, neglect, exploitation, or mistreatment,] dated October 2022. Record review of the facility's [Significant [NAME] in Condition, Response Policy] dated January 2022 indicated: if, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the licensed nurse or nurse supervisor should be made aware. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676421 If continuation sheet Page 5 of 14 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 02/07/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 18 Residents (Resident #1 and Resident #2) reviewed for accidents and hazards. 1. The facility failed to ensure Resident #1 received microwaved food, from an outside source, at a temperature for safe elderly consumption which resulted in a second-degree burn. 2. The facility failed to ensure Resident # 2 had total assistance while consuming a cup of hot coffee resulting in medical attention for skin irritation. On 2-5-2024 at 7:54 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 2-7-2024 at 2:40 PM, the facility remained out of compliance at a scope of isolated with a severity level of potential of more than minimal harm, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. Findings included: 1. Record review of the facilities investigation report, dated 1-24-2024, indicated Resident #1 asked CNA A for assistance with heating up a bowl of soup on 1-16-2024. CNA A heated the soup and returned it to Resident #1 on his bedside table. Resident #1 accidently knocked the soup from the bedside table onto his right lower torso area having yelled out in pain. CNA A returned shortly to render aid, where she cleaned him, and provided clean linen and clothing. CNA A left the room. On the next day, 1-17-2024, CNA B was assisting Resident #1 with a bed bath and noticed Resident #1's right lower torso area was red. CNA B asked LVN C for help, where it was discovered that Resident # 1's right lower torso area was red with blisters. CNA A was suspended pending investigation, subject to discharge, for having known of the spilled soup and having not reported the incident to the charge nurse. In-service educations for hot beverages and food temperature proceeded. Record review of Resident #1 AR, dated 2-6-2024, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with orthostatic hypotension (which was lightheadedness or dizziness when standing after sitting or lying down); unspecified lack of coordination; need for assistance with personal care; and mild cognitive impairment. Record review of Resident #1's Quarterly MDS assessment, dated 12-8-2023, indicated Section CCognitive Patterns, BIMS Score Summary reflected Resident #1 had a BIMS Score of 6. A BIMS Score of 6 indicated Resident #1 had severe cognitive impairment. Acute Onset Mental Status Change indicated Resident #1 continuously presented with inattention, disorganized thinking, and an altered level of consciousness described as vigilant, meaning he startled easily to any touch or sound. Section GGFunctional Abilities and Goals, Self-Care, indicated Resident #1 required set-up or clean-up assistance (which meant the helper sets up or cleaned up after the resident completed the activity) for eating. Record review of Resident #1's Progress Notes, dated 1-17-2024 indicated CNA B was changing resident when it was observed that the resident had a burn with a thick blister to the lateral right thigh. Aide alerted nurse. The resident stated that he spilled a container of soup, brought from home, on him last night. The resident stated he did not tell anyone at the time of incident. Wound care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676421 If continuation sheet Page 6 of 14 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 02/07/2024 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 0689 performed per NP: cleanse with NS, pat dry, apply Silvadene cream, and dress with dry dressing. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #1's Progress Notes, dated 1-17-2024 indicated burn incident to the right-side hip area. This NP notified today by nurse of incident. Resident reported accidentally hitting the bedside table and knocked over the soup that was brought to him by family. Assessment of site completed with redness noted to right side hip area, non-tender to touch, denies pain at this time, able to move extremities with no limitations. Stable at baseline in good spirits with intermittent confusion. Care discussed with nursing, new orders noted for Silvadene cream, dress with dry dressing. Nursing and wound care to monitor closely for delayed complications. Residents Affected - Few Record review of Resident #1's Progress Notes, dated 1-22-2024 indicated Resident was seen by wound doctor for burn to the right side (flank). Area was cleaned with n/s and anesthesia was achieved using topical benzocaine. Then with surgical technique, 15 blade was used to surgically excise 21.00 cm of devitalized tissue and necrotic subcutaneous level tissues along with sought and biofilm were removed at a depth of 0.15cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 70% to 35%. Hemostasis was achieved and a clean dressing was applied. Resident has been made aware of the condition of the skin and the treatment that is in place. Record review of Resident #1's Progress Notes, dated 1-29-2024 indicated the resident was seen by wound doctor for burn to the right flank and wound with improvement observed on this visit by evidenced by decreased surface area and decreased necrotic tissue increased granulation. Wound was cleaned with normal saline and anesthesia was achieved using topical benzocaine. Then with surgical technique 15 blade was used to surgically excise 12.6cm of devitalized tissue and necrotic subcutaneous level tissues along with slough, biofilm was removed at a depth of 0.15cm and healthy bleeding tissue was observed. As a result of this procedure the nonviable tissue in the wound bed decreased from 50% to 20%. Hemostasis was achieved and a clean dressing was applied. The resident has been made aware of the condition of burn and the treatment that is in place. Record review of Resident #1's Progress Notes, dated 2-5-2024 the resident was seen by wound md for burn to the right flank area with improvement observed on this visit evidenced by decreased surface area. Wound was cleaned with n/s and anesthesia was achieved using topical benzocaine and resident has no complaint of pain or discomfort during this assessment. Then with clean surgical technique, 15 blade was used to surgically excise 9.00cm of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a depth of 0.1cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 30% to 5%. Hemostasis was achieved and a clean dressing was applied. The resident has been made aware of the condition of the wound and the treatment that is in place. Record review of Resident #1's skin evaluation, dated 1-18-2024, reflected a fluid filled blister to the upper right side of the torso area with surrounding skin red in color and blister intact, the right lower side of torso area had fluid filled blister with redness to surrounding skin. Record review of Resident #1's skin evaluation, dated 1-23-2024, reflected a burn to the resident's right flank. It was 6 centimeters by 10 centimeters and 1 centimeter deep. The resident would continue to receive wound care on wound rounds. Record review of Resident #1's skin evaluation, dated 1-25-2024, reflected burns to the resident's right side. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676421 If continuation sheet Page 7 of 14 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 02/07/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of Resident #1's skin evaluation, dated 2-1-2024, reflected the resident was being treated for a burn wound to the resident's right side. Record review of Resident #1's skin evaluation, dated 2-5-2024, reflected the resident was being treated for a burn wound to the resident's right side. Record review of Resident #1's Order Summary Report indicated an order, dated 1-29-2024, to clean right flank, pat dry, and apply alginate calcium and collagen powder, and cover with gauze island dressing every 24 hours as needed for burn. Record review of Resident #1's Order Summary Report indicated an order, dated 2-6-2024, to clean right flank, pat dry, and apply xeroform and apply gauze island on day shift for burn. Record review of Resident # 1's IDT BIMS Assessment, administered on 1-18-2024, indicated Resident # 1 had a BIMS Score of 11. A BIMS Score of 11 indicated Resident #1 had moderate cognitive impairment. Record review of Resident #1's CP indicated a [Focus Area] created 1-18-2024 and evidenced by actual impairment to skin integrity R/T burn to right side hip from soup and treatment was documented. Resident was seen by wound physician on 1-22-2024, 1-29-2024, and 2-5-2024. The [Intervention] initiated on 1-18-2024 was to follow facility protocols for treatment of injury. A second [Focus Area] created 6-2-2023 evidenced by risk of impaired cognitive function/dementia or impaired thought was documented. The [Intervention] created on 6-2-2023 was to give step-by-step instructions one at a time as needed to support cognitive functions and report any changes in cognitive function, specifically in decision making ability, memory, recall, awareness of surroundings and other, difficulty expressing self, difficulty understanding others, sleepiness, or confusion. A third [Focus Area] created 6-2-2023 evidenced by risk of visual function R/T aging was documented. The [Intervention} created 6-2-2023 was to monitor, document and report to the physician any signs of acute eye problems; changes in ability to perform ADLs, decline in mobility, second visual loss, double vision, tunnel vision, blurred vision, or hazy vision. Interview and observation on 2-5-2024 at 10:30 AM with Resident #1 revealed Resident #1 was lying in bed relaxing. His tray side table had two thin rectangular non-slip pads. He stated he just got the non-stick pads today, and they were there to help things from slipping off his table. On the evening of 1-16-2024 he asked CNA A to heat up some soup for him. When CNA A brought the soup back, he stated she placed it on the bed side table and left. He sat up in bed and knocked the soup over by accident onto his right-side lower torso area, which caused him to holler out in pain. He gauged the pain on a pain scale of 1-10, with 0 being no pain and 10 being the worst. Resident #1 stated the pain he felt after spilling his soup on his right-side lower torso area was an 8 out of a possible 10. When he called for help after he spilled his soup, he stated CNA A came back to his room, who changed his clothes and his bedding. He did not remember if CNA A asked him if he was in any pain. No other staff member came to his room to look at his skin or to see if he needed medical attention. During the interview, CNA E came to the room and moved back Resident #1's covers to expose his right-side lower torso area. His right-side lower torso area was covered with two light pink bandages. Record review of CNA A's counseling and disciplinary notice dated 1-18-2024 having pertained to Resident #1, indicated CNA A was suspended, pending investigation, subject to discharge. Employee knew (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676421 If continuation sheet Page 8 of 14 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 02/07/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few that a resident spilled hot food on them and failed to notify the charge nurse of the incident / change of condition. Record review or Resistant #1's SBAR Communication form, dated 1-17-2024, indicated Resident#1 had a change in condition, due to a burn, which occurred on 1-16-2024. Record review of the in-service training dated 1-18-2024, on [Hot Beverages and Food Temperature,] provided by the facility, indicated that [Coffee and Hot Water for all Residents Cannot Exceed 135 degrees Fahrenheit.] The training consisted of 5 instructions: (1) dietary staff will log copy temperatures daily to ensure that the temperature does not exceed 135 degrees Fahrenheit; (2) canned soup should be warmed up to 130 degrees Fahrenheit unless it is leftover and then you reheat it to 165 degrees Fahrenheit for 15 seconds; (3) recommendations for the elderly safe consumption were 135 to 150 degrees Fahrenheit; (4) when we reheat resident's food, the preference is for the kitchen to reheat the food. If the kitchen is closed, we must test food temperatures with a food thermometer before giving the resident the item for safe consumption, and; (5) the thermometers were located in the drawer by microwave. Please ensure you clean before and after use with alcohol swab. Record review of the facility's [Significant [NAME] in Condition, Response Policy] dated January 2022 indicated: if, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the licensed nurse or nurse supervisor should be made aware. 2. Record review of the facilities investigation report, dated 2-6-2024, indicated Resident #2 asked CNA J for a cup of coffee on 2-3-20 at 7:30 AM. CNA J retrieved a cup of coffee from the coffee dispenser and returned the cup of coffee to Resident #2. CNA J asked Resident #2 if he was ok to drink the coffee and Resident #2 stated he was. After a couple of minutes, CNA J stated she heard Resident #2 having yelled for help. When CNA J reported to Resident #2's room, she witnessed his coffee was spilled on the upper side of his left leg at the groin area. CNA J stated she immediately retrieved the nurse. LVN D assessed Resident #2 and noted redness to the area of the skin where the coffee was spilled. CNA J was educated, one on one, for safety with warm liquids. In-services for ANE and hot beverages and food temperatures proceeded. Record review of Resident #2's AR, dated 2-6-2024, indicated an [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with Parkinson's Disease, with fluctuations (which was a progressive disorder that affected the nervous system and parts of the body controlled by nerves, along with fluctuations in the ability to move); cognitive communication deficit; Unspecified lack of coordination; and the need for assistance with personal care. Record review of Resident #2's Quarterly MDS, dated [DATE], indicated Section C- Cognitive Patterns, BIMS Score Summary reflected Resident #2 had a BIMS Score of 11. A BIMS Score of 6 indicated Resident #2 had moderate cognitive impairment. Acute Onset Mental Status Change indicated Resident #2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676421 If continuation sheet Page 9 of 14 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 02/07/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few continuously presented with inattention. Section GG- Functional Abilities and Goals, Functional Limitation in Range of Motion indicated Resident #2 had impairment on both shoulders, elbows, wrists, and hands. Self-Care indicated Resident #2 substantial/maximal assistance (which meant the helper did more than half of the effort) for eating. Record review of Resident #2 CP indicated a [Focus Area] created 1-11-2024 evidenced by the resident having Arthritis. The [Intervention] initiated on 1-11-2024 was to monitor and report to nurse any change in level of activity or ability to perform; monitoring, document, and report to physician complications related to arthritis such as pain, joint stiffness, swelling, decline in mobility, decline in self-care ability, contracture formation, and joint shape changes. A second [Focus Area] created on 12-12-2022 was evidenced by ADL self-care performance deficit R/T weakness. The [Intervention] created on 2-5-2024 was all staff to assist with ADLs. Record review or Resistant #2's SBAR Communication form, dated 2-3-2024, indicated Resident #2 had a change in condition, due to a skin discoloration, which occurred on 2-3-2024. Record review of Resident #2's skin evaluation, dated 2-3-2024, reflected skin irritation to the resident's left inner thigh. Record review of Resident #2's skin evaluation, dated 2-5-2024, reflected to continue treatment to the resident's left inner thigh. Record review of Resident #2's Progress Notes, dated 2-3-2024, reflected this nurse heard resident yelling, proceeded to resident's room, prior to arriving in resident room saw CNA J exit resident's room, and told this nurse that the resident had spilled coffee on himself. This nurse and CNA J entered the resident's room to see that the resident had spilled coffee on the sheet that was covering him from the waist down. The sheet was removed; the resident was assessed. The resident's left inner and bottom of left buttock had some skin irritation and redness, skin intact. Asked the resident what happened, and the resident stated that he spilled the coffee on himself, and it was hot. The resident cleaned up by can x 2, clean brief applied to resident, and bed linen changed. The NP, the DON, and the administrator were notified. Cleanse resident left inner thigh and left buttocks with NS, pat dry, and apply Silver Sulfadiazine Cream 1% BID. The resident's wife was notified. The ordered treatment was initiated. The coffee temperature was taken and was within normal limits. The resident denied pain. The resident stated that it was hot when it happened but now, he feels better, and he will be okay. The CNA was educated on the importance observing food and/or beverages for steam and notifying the nurse, prior to giving the resident food and/or beverages if the CNA thinks that the food and/or beverages was too hot. CNA verbalized understanding. Record review of Resident #2's Order Summary Report indicated an order, 2-3-2024, to cleanse left inner thigh with NS, pat dry, and then apply silver sulfadiazine external cream 1% until healed. Leave open to air. Two times a day for skin irritation. Record review of the in-service training dated 2-3-2024, on [Abuse and Neglect] provided by the facility, indicated that [abuse is prohibited. Every resident has a right to be free from abuse, neglect, misappropriation of resident property, and exploitation] The training indicated residents must not be subject to abuse by anyone, including, but not limited to facility staff, other residents, consultants, volunteers, staff of other agencies, resident representatives, family, friends, or other individuals. Abuse must be reported to the abuse coordinator immediately. The abuse coordinator is the ADM. Types of abuse are, but not limited to our physical, mental, financial, restraints, verbal, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676421 If continuation sheet Page 10 of 14 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 02/07/2024 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 0689 and misappropriation of funds. Level of Harm - Immediate jeopardy to resident health or safety Record review of the facility's [Abuse Prevention Policy,] dated September 2017. Record review of the facility's [reporting alleged violations of abuse, neglect, exploitation, or mistreatment,] dated October 2022. Residents Affected - Few Record review of the in-service training dated 2-3-2024 on [Hot Beverages and Food Temperature,] provided by the facility, indicated that [Coffee and Hot Water for all Residents Cannot Exceed 135 degrees Fahrenheit.] The training consisted of 5 instructions: (1) dietary staff will log copy temperatures daily to ensure that the temperature does not exceed 135 degrees Fahrenheit; (2) canned soup should be warmed up to 130 degrees Fahrenheit unless it is leftover and then you reheat it to 165 degrees Fahrenheit for 15 seconds; (3) recommendations for the elderly safe consumption were 135 to 150 degrees Fahrenheit; (4) when we reheat resident's food, the preference is for the kitchen to reheat the food. If the kitchen is closed, we must test food temperatures with a food thermometer before giving the resident the item for safe consumption, and; Please see nurse before giving any liquids/food for verification of safe consumption. (5) the thermometers were located in the drawer by microwave. Please ensure you clean before and after use with alcohol swab. Interview, observation, and record review on 2-5-2024 at 10:55 AM with CNA E revealed that residents have asked her to heat their food for them in the past. She said there was a microwave in the nutrition room at the nurse's station. Having reheated resident's food before, she admitted that she had not used a thermometer to check for the food's temperature until the incident with Resident #1's soup on the evening of 1-16-2024. Since then, she stated that the staff had been trained to check the resident's food with a thermometer prior to returning it to the resident. CNA E demonstrated her knowledge of training provided by the facility having attempted to heat a cup of water in a plastic coffee cup in the microwave. The observation reflected CNA E having entered the nutrition room, near the 300 hall, where she looked for a thermometer. CNA E opened the drawer under the microwave, where the thermometer was visible, but she could not locate it. She opened and shut the drawer 3 times before she finally located the thermometer. There were no alcohol swabs. CNA E had to leave the nutrition room and locate alcohol swabs, which were located on the medication cart. When she returned to the nutrition room, she placed the cup of water in the microwave. CNA E did not know a guesstimated time to put the cup of water in the microwave. When the timer went off, she wiped the thermometer and placed it in the cup, the temperature was 145 degrees Fahrenheit. CNA E then stated that she would wait for the coffee, or whatever the item was, to cool to 135 degrees Fahrenheit before having given it to the resident. CNA E stated having known a start point to put a particular item in the microwave to heat to 135 degrees Fahrenheit would help, because having to wait for it to cool risked bringing something to a resident that was too hot. She also stated that alcohol swabs should have been located in the drawer next to the thermometer because not having one handy risked using a thermometer that was not clean. The only written guidance in the nutrition room for reference, near the 300 hall, was a square sticker on the refrigerator with a picture of a thermometer. The sticker indicated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676421 If continuation sheet Page 11 of 14 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 02/07/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few proper holding temperatures for foods were above 135 degrees Fahrenheit or below 41 degrees Fahrenheit. This sticker informed the reader of safe holding temperatures to avoid food borne pathogens, not to designate safe temperatures for elderly consumption. CNA E reviewed the in-service training, and her name was not recorded to mark attendance. Interview, observation, and record review on 2-5-2024 at 11:20 AM with CNA F revealed she had heard Resident #1 spilled soup on himself on 1-16-2024. If she had been the CNA on duty, she stated she would have wanted to see where the soup was spilled and get the nurse to check for injuries. According to CNA F, CNA A failed in her duties having not reported the spill to the nurse. CNA F entered the nutrition room, near the 700 hall, and demonstrated her knowledge from the in-service training, called [Hot Beverages and Food Temperature,] dated 1-18-2024. CNA F stated that the coffee was supposed to be reheated between 135-150 degrees Fahrenheit. She said that coffee was safe to serve to residents at 145 degrees Fahrenheit. CNA F correctly demonstrated the process to heat an item, but she was incorrect about the coffee temperature being safe to serve at 145 degrees Fahrenheit. CNA F was provided a copy of the in-service training for [Hot Beverages and Food Temperature,] dated 1-18-2024. When she reviewed the in-service training, she became confused because the in-service training indicated more than one example of safe temperatures that were safe for elderly consumption. She noted the heading of the in-service training stated coffee and hot water for residents cannot exceed 135 degrees Fahrenheit, but (3) recommended elderly safe consumption was 135-150 degrees Fahrenheit. She was also confused because the instructions for soup (2) stated soup should be warmed up to 135°F unless it is left over and then you reheat it to 165°F for 15 seconds. The only written guidance in the nutrition room for reference, near the 700 hall, was a square sticker on the refrigerator with a picture of a thermometer. The sticker indicated the proper holding temperatures for foods was 135°F or 41°F; this sticker informed the reader of safe holding temperatures to avoid food borne pathogens, not to designate safe temperatures for elderly consumption. CNA F reviewed the in-service training, and her name was recorded marking attendance. Interview, observation, and record review on 2-5-2024 at 11:45 AM with CNA B revealed she was in Resident #1's room on the evening of 1-17-2024 to give Resident #1 a bed bath. When she was about to begin, Resident #1 pointed to his right lower torso area, referring to the area he spilled his soup, and asked if she was going to do anything about it, because [it was uncomfortable.] She pulled back Resident #1's covers and clothing to reveal a big bubble blister. She immediately got LVN C for a medical assessment. Both CNA B and LVN C returned to the room where she observed LVN C assess the injury. CNA B observed the big bubble blister was seeping clear liquid. After the wound was dressed by LVN C, CNA B continued with Resident #1's bed bath. If she were on duty the night of 1-16-2024, when Resident #1 spilled his soup, she stated she would have asked the nurse to check his skin. CNA B stated CNA A neglected Resident #1 by not reporting the matter to the nurse. Prior to the incident with Resident #1 having spilled his soup, CNA B stated there was no direction given to CNAs that pertained to food and beverage temperatures for elderly safe consumption. CNA B entered the nutrition room, near the 300 hall, to demonstrate her knowledge of the in-service training for [Hot Beverages and Food Temperature,] dated 1-18-2024. At this time, the thermometer was located in the same location as before, but the thermometer was placed it in a 1-gallon size plastic bag and had used a black magic marker to indicate a temperature range of 135-145 degrees Fahrenheit, which was not congruent with the in-service training and safe consumption for the elderly. However, CNA B correctly demonstrated the process of heating up a plastic cup of water not to exceed 135 degrees Fahrenheit. She started at 30 second intervals and brought the temperature up gradually so it did not exceed 135 degrees Fahrenheit. CNA B reviewed the in-service training, and her name was recorded marking (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676421 If continuation sheet Page 12 of 14 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 02/07/2024 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 0689 attendance. Level of Harm - Immediate jeopardy to resident health or safety Interview, observation, and record review on 2-5-2024 at 12:40 PM with CNA A revealed Resident #1 asked her to heat up some soup for him on the evening of 1-16-2024. The soup was a single serve microwavable soup. She did what she was asked and returned the soup to Resident #1's bedside table. She stated she placed it on the bed side table and told Resident #1 to wait until it cooled off, because she stated it was steaming. CNA A left the room to address other duties. CNA A guesstimated 5-10 minutes passed when she noticed his call light was activated. After an additional 2-3 minutes, she stated she entered the room for the call. When she entered the room, she learned that Resident #1 had spilled his soup on his right lower torso area. She removed Resident #1's clothing and bedding then provided clean replacements. After, she left the room to address her duties. She did not report the incident of Resident # 1 having spilled soup, which she referred to as steaming on his right lower torso area. Prior to the incident on 1-16-2024, CNA A stated she had not received any formal training on food temperatures for elderly safe consumption. However, after the incident on 1-16-2024, the facility began to train staff on hot beverages and food temperature. CNA A entered the nutrition room, near the 700 hall, to demonstrate the training she received for [Hot Beverages and Food Temperature] on 1-18-2024. CNA A filled a plastic coffee cup with water and placed it in the microwave and heated the water with an increments of 30 seconds. She took the liquids temperature for two intervals of heating but did not use an alcohol wipe before inserting the thermometer. She stopped at 117 degrees Fahrenheit and said she would have provided it to the resident. CNA A reviewed the in-service training and was unable to determine the safe temperature for elderly consumption for a can of soup. The training initially stated that 135 degrees Fahrenheit was the safe temperature for soup, but the training also said it could be heated to 135 is it was considered a left over. CNA A reviewed the in-service training, and her name was recorded marking attendance. Residents Affected - Few Interview and record review on 2-5-2024 at 1:31 PM with the DM and the [Hot Beverages and Food Temperature] in-service on 1-18-2024 revealed she was not consulted by the ADM with the information contained in the training. According to the DM, the different temperatures in the trainings were not consistent. Temperature logs for coffee in the month of January 2023 and February 2023 indicated all 3 coffee station areas, Shawnee, Express, and Activity, ranged between 130-135 degrees Fahrenheit. Interview on 2-5-2024 at 1:49 PM with LVN C revealed she was on duty the evening of 1-17-2024, around 5:00 PM, when CNA B reported Resident #1 needed medical attention. When LVN C entered the room, she noticed Resident #1's right lower torso area was red. LVN C pulled back the sheet and discovered two blistered areas, one of which one had popped exposing raw skin. She informed the nurse practitioner, applied Silvadene cream, and dressed the wound. LVN C stated Resident #1 told her [it hurt at the time it happened.] LVN C had been a nurse for 17 years with experience treating burns and characterized Resident #1's injury either a 1st degree or a 2nd degree burn. Furthermore, she stated the skin would have continued to burn until the burn stopped on its own, or if something were applied like cold water, ice, or Silvadene cream. Had the burn been treated sooner, it might have had a better outcome. LVN C stated CNA A should have told the nurse after she learned Resident #1 spilled hot soup on himself. Also, neglect did not have to be a willful act. LVN C completed a SBAR form, to note a Change in Condition, for Resident #1's burn on 1-17-2024 at 5:00 PM. The wound care was assigned to the wound care nurse, LVN G, because raw skin was exposed and there was a greater risk of infection. According to WebMD at [https://www.webmd.com/drugs/2/drug-4910silvadene-topical/details] Silvadene cream was a medication used with other treatments to help prevent and treat wound infections in patients with serious burns. Group interview on 2-5-2024 at 2:10 PM with LVN G (wound nurse), Physician H (wound doctor), and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676421 If continuation sheet Page 13 of 14 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 02/07/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Physician I (wound doctor) revealed a consensus that the wound on Resident #1 was classified as a 2nd degree burn. LVN G stated that CNA A should have reported the soup spill to the nurse for a medical assessment. Interview and record review on 2-5-2024 at 3:00 PM with the ADM revealed the CNA staff who demonstrated heating items in the microwave were confused after they were interviewed. The ADM was shown the in-service for [Hot Beverages and Food Temperature] on 1-18-2024 and was informed that the demonstration and the interview questions came directly from the in-service [Hot Beverages and Food Temperature] on 1-18-2024. The ADM stated that the information on the in-service for [Hot Beverages and Food Temperature] on 1-18-2024 was taught differently. However, she understood the actual words and temperature ranges contradicted each other. Staff were being re-trained. Interview and observation on 2-5-2024 at 5:24 PM with Resident #2 revealed he asked CNA J to bring him a cup of coffee on 2-3-2024 around 7:30 AM. CNA J brought him a cup of coffee and put it in his right hand then left the room. After a brief few moment, he stated he dropped the coffee in his crotch and yelled out in pain because it hurt a lot when it happened. He stated he was in pain for about 30 seconds. He was asked to demonstrate how he held a plastic coffee cup, the same kind used by the facility. Before he could accept the coffee cup, he needed to put down his call-light button, which was in his right hand. Observations reflected his right arm, right forearm, and his right hand moved very slowly. Resident #2 displayed difficulty manipulating his fingers to release his grasp of the call-light button and his arm moved unsteadily when he reached out to grab the plastic cup. Resident #2 did not have use of his left arm, left forearm, or his left hand. Interview on 2-5-2024 at 5:32 PM with CNA K revealed she has provided care for Resident #2 many times. She stated he did not have proficient use with his right hand sometimes it moved in a jerking motion. She stated she would not have given Resident #2 a cup of hot coffee and left him [NAME][TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676421 If continuation sheet Page 14 of 14