Health inspection·November 24, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to elect his medical care and procedures. ADM stated that the facility has consulted with their legal department, and it was felt that the appointment of a guardian was in the best interest of the resident. ADM stated that appointments are being sought through the local courts. ADM stated that this is a long process in this county and no appointment has been made yet. ADM stated the application process began in [DATE]. ADM claimed that the lack of a designated POA has not interfered with the resident's care. In an interview on [DATE] at 12:43 PM, SW A with a local hospital, indicated they were involved in the discharge planning of Resident #1 during his most recent hospital stay. SW A stated on or about [DATE], she reviewed the DPOA provided for Resident #1 and questioned its legality as it listed SSA and SSM as the Resident's agents, but Resident #1 had no designated medical decision maker. SW A stated that she spoke to the facility (possibly ADM) and highly suggested they apply for guardianship on behalf of Resident #1. The facility stated they would speak to their liaison. SW A stated Resident #1 was confused throughout his stay, unable to make his own decisions, and lacked family willing to serve as POA. SW A stated this made Resident #1 appropriate for guardianship. SW A stated the hospital was able to secure a valid out of hospital DNR on behalf of Resident #1 prior to his discharge on [DATE]. SW A stated the documentation provided by the facility did not include a valid medical POA.In an interview on [DATE] at 1:05 PM, DON stated that Resident #1 is able to understand English, but his understanding was limited. In an interview on [DATE] at 1:15PM, SSA verified she was an assistant to the facility's SW. SSA stated that she had been employed with the facility for 8.5 years, starting as a CNA, then moving into the transporter role, and then as an SSA. SSA stated Resident #1 was initially homeless and taken in by friends. Resident #1 was assaulted and hospitalized . He was discharged to the facility and is now a LTC resident. SSA stated that Resident #1's emergency contact is listed as the resident's niece , but she really isn't biologically kin to the resident. She was not considered the resident's RP but was included in care plan meetings. SSA stated that the need for a POA came up during a care planning meeting. Resident #1's niece refused to fulfill that role. Resident #1's next emergency contacts also declined to serve in the role of POA as well. SSA stated that Resident #1 chose his code status. SSA stated that Resident #1 is Spanish speaking only, but SSM explained to the resident what a code status was, and the resident elected to a code status of DNR. SSA stated that when the decision-making process was explained to Resident #1's next-of-kin or emergency contacts and the need for a POA, they all said they did not want to be the designator due to possible financial and physical implications. SSA claimed at the time Resident #1 signed the DPOA naming her as his agent, he was clear, sound mind and was alert and oriented. SSA stated that initially Resident #1's code status was full code, but the hospital had DNR paperwork and so the resident's code status was changed. SSA stated that the hospital case manager advised facility staff of the possible conflict regarding the DPOA the resident signed naming SSA and SSM as his agent. SSA stated that she and SSM felt the DPOA was appropriate because no one else wanted to fulfill that role and SSA was close to the resident and cared for him and would purchase items for him that he needed. SSA stated that they consulted with their legal department about this and were told this type of agreement was allowed and legal. SSA stated it was SSM who made the call to their legal department. SSA stated that it was felt that the DPOA signed was in the best interest of the resident and was legally appropriate. SSA claimed that she and SSM only signed as witnesses but the resident signed for themself. SSA denied they were ever designated as POA. SSA stated that typical POA duties would have included relaying the resident's wishes and decisions to others, speaking on the resident's behalf, and moral support. SSA further explained that a POA covered medical related issues. But if the resident was alert and oriented, the resident would make their own decisions. SSA stated if the (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 11/24/2025 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)

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's cognition was off then the agent would make the decisions but not financial decisions. SSA stated that SSM handles these types of issues or designations and SSA takes directive from SSM. SSA stated that she and SSM are neither the POA nor DPOA now. SSA stated there are no other residents that have declared SSA or SSM as their agent or POA. In an interview conducted on [DATE] at 2:30 PM, ADM stated that Resident #1 signed himself in for care at the facility and that Resident #1 was alert and oriented at that time. ADM stated Resident #1 was a full code status upon admission. ADM stated that residents' code status is revisited and discussed at every care planning meeting. ADM confirmed that care planning meetings occur every 3 months. ADM stated that the facility always had a translator available through a language line service if needed. ADM stated SSM spoke Spanish as well. ADM stated Resident #1's first language was Spanish, but he also spoke English. ADM stated that the DPOA that was signed naming staff as Resident #1's agents was never utilized. ADM stated an out of hospital DNR was obtained by the hospital during the resident's most recent admission. ADM stated that Resident #1 has overseen his own finances throughout his time at the facility. ADM stated Resident #1 signed a DNR on [DATE] after the need for such was identified. ADM stated that SSA or SSM never acted outside their legal scope regarding the DPOA. ADM stated that their legal department was consulted and ATY A advised them guardianship should be sought on behalf of Resident #1 and staff should not be listed as the Resident's agents. ADM stated that Resident #1 is listed as their own primary decision maker because the family did not want to act on his behalf. ADM was advised that no filing for guardianship could be located or established. ADM then stated she was unsure of the status of the guardianship application as SSM was handling that. ADM also stated that SSM explained to ADM that the utilization of the DPOA for these purposes was a common practice at her former place of employment and SSM did not think it was considered inappropriate. An interview was attempted on [DATE] at 3:00 PM with ATY A, but contact could not be established. A message was left for ATY A requesting a return telephone call, but none was received.In an interview on [DATE], at 3:00 PM, ADM stated that ATY A was out of the office and could not be reached. ADM stated that she contacted their legal department on this date prior to this interview and was told the directive given by ATY A was all that could and should be provided. Per ADM, their legal department confirmed the DPOA was not the most appropriate course of action and guardianship should have been sought. ADM stated that she also spoke to SSM who stated that SSM was advised to begin the due diligence process for the appointment of a guardian, which she had started by locating 2 additional family members. Per ADM, the legal process had not been initiated because it takes time to complete the due diligence process. In an interview on [DATE] at 3:40PM, SSM stated she began her employment with this facility in February 2025. SSM stated that she is a licensed SW and has experience and knowledge of the geriatric population. SSM stated that she became aware of the need for a POA for Resident #1 at a care planning meeting. SSM stated Resident #1 wanted SSA to be his POA. SSM stated that she did not consult with their legal department prior to implementation of the DPOA. SSM said that ADM did consult with their legal department after the implementation. SSM stated that the hospital SW brought the issue to ADM's attention and ADM then contacted their legal department. SSM stated that she anticipated Resident #1's lack of family would become a problem, so she contacted their OMB on or about [DATE]. SSM stated no response was received from OMB so they proceeded with the POA that was implemented in [DATE]. SSM stated that several care conferences were held between [DATE], and [DATE], discussing the need for a POA; however, SSM admits the documentation is missing from PCC. SSM stated that she has counseled SSA on the importance of inputting these notes. SSM stated that she does have her own notes though and read from them over the phone. SSM stated that on [DATE], SSA made arrangements with Resident #1's niece to come (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 11/24/2025 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)

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few in to sign a POA but the niece did not show. SSM stated that there has been no formal application or legal filing made regarding guardianship for Resident #1 as she needed to get her ducks in a row and became stuck during the process. SSM stated that she had attempted to contact the courts to determine what would be needed but she was unable to establish contact. SSM stated that she anticipated the need for a medical certification, which she obtained, and a possible psychological evaluation. She stated that she planned to seek this evaluation when she returned to the office after the holiday. SSM stated at this time, she and SSA are still the legal agents for Resident #1 and are responsible for the duties listed in the DPOA.An interview with OMB A was attempted on [DATE] at 3:12 PM. Contact was not established at that time but was later established. OMB A stated that under these circumstances, they would have instructed staff to seek guidance from their legal team as the relationship the DPOA established with staff could be considered a conflict of interest. OMB A stated that they were not contacted by facility staff in relation to this issue or this resident.Record review of Resident #1's admission Agreement implemented and signed by the resident on [DATE], revealed in part:The Facility may petition a Court to appoint a Guardian and/or take other legal action if the Facility reasonably believes that the Resident's needs are not being properly met, or the duties imposed by this Agreement are not being fulfilled by the Resident Representative.The admission Agreement was signed by Resident #1. Resident #1 did not identify or elect a Resident Representative in the agreement. Record review of the DPOA signed by Resident #1 on [DATE], revealed SSA (facility staff member) was elected as Resident #1's agent who was able to act for Resident #1 in any lawful way with respect to the following powers: Real Property Transactions Tangible personal property transactions Stock and bond transactions Commodity and option transactions Banking and other financial institution transactions Business operating transactions Insurance and annuity transactions Estate, trust, and other beneficiary transactions Claims and litigation Personal and family maintenance; Benefits from Social Security, Medicare, Medicaid, or other government programs or civil or military service Retirement plan transactions Tax matters Digital assets and the content of electronic communicationThe Special Instructions indicated by Resident #1 entitled SSA to reimbursement of reasonable expenses incurred on [NAME] behalf and to compensation that was reasonable under the circumstances. Resident #1 elected SSM (facility staff member) to be his successor agent in the event SSA died, became incapacitated, resigned, or refused to act, or was removed by court order. The DPOA was witnessed and notarized by another staff member at the facility. Record review of Resident #1's Progress Notes revealed the following: [DATE]: Social Services reviewed once more about signing a POA with niece once more she declined due to her religion. (Resident #1) wishes to be cremated and asked for assistance in securing affordable services. He indicated when it is time to go to let him go. SSD will update a code status change. [DATE]: SSA set up [name] funeral services to come out and meet with resident regarding cremation as resident would like to plan accordingly. [DATE] Social Services Summary written by SSM: met with.funeral director from [name]Funeral Home from [city] assisted in helping (Resident #1) honor his wishes of being cremated. Everything was discussed, completed [and witnessed].[preburial ] arrangements saved, and copy provided to (Resident #1) as well.Record review of the Certificate of Medical Examination for Guardianship revealed DO A personally examined Resident #1 on [DATE] and asserted their medical opinion that Resident #1 was incapacitated. DO A recommended the appointment of a guardian of the person and estate in order to protect Resident #1's health, safety, and financial interests.Record review of Resident #1's MDS assessment dated [DATE], reflected Resident #1 had a BIMS score of 2 out of 15, indicating severe cognitive impairment. Record review of Resident #1's MDS assessment dated [DATE], reflected Resident #1 had a BIMS score of 7 out of 15, indicating severe (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 11/24/2025 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)

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete problems with thinking.Record review (online search) conducted on [DATE] at 2:55 PM, revealed no application, petition, or legal filing existed in relation to the guardianship of Resident #1 in the local County Court record system.Record review of the facility's policy and procedures regarding Resident Rights dated [DATE], and amended on [DATE], revealed residents have the right to be informed of, and participate in their treatment, the right to self-determination, the right to privacy and confidentiality, the right to a safe environment, the right to file grievances, the right to choose their attending physician, the right to information and communication, and the right to contact with external entities. Event ID: Facility ID: 676421 If continuation sheet Page 5 of 5