Health inspection·April 14, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #1) of 5 residents reviewed for care plans. The facility failed to ensure Resident #1's care plan was updated to reflect the resident no longer being treated for a yeast infection. This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met. Findings Included: Review of Resident #1's face sheet dated 04/14/2025 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included essential primary hypertension(a condition characterized by persistently elevated blood pressure without an identifiable underlying cause), unspecified dementia( where the underlying cause or specific type of dementia is not determined , despite a medical evaluation), and depression(sadness). Review of Resident #1's quarterly MDS assessment, dated 03/14/2025, reflected a BIMS score of 1, indicating she had severe cognitive impairment. Review of Resident #1 's care plan dated 04/13/2025 and date initiated 03/11/2025 reflected Resident #1 had an active yeast infection. Review of Resident #1's physician order dated 03/11/2025, reflected that Resident # 1 had order for Terconazole(antifungal medication used to treat yeast infections in the vagina) vaginal suppository 80 MG. Insert vaginally at bedtime for 3 days. Review of Resident #1's MAR revealed Resident # 1 received Terconazole vaginal suppository 80 MG on 03/12/2025, 03/13/2025, and 03/14/2025. During an interview with the ADON on 04/14/2025 at 2:15 PM, the ADON stated she was responsible for making sure the care plan reflected Resident #1 yeast infection had been resolved. The ADON stated she had missed updating Resident # 1 care plan to reflect it resolved. The ADON stated the care plan communicated care that needed to be provided to residents. The ADON stated if the care plan was not (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 676421 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 04/14/2025 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)