Health inspection·December 12, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few apply A & D ointment (a skin protectant to help relieve and heal minor skin irritations and conditions) around stoma site (opening that collected waste) to prevent skin breakdown every shift.A record review of Resident #1's physician's order, dated 11/08/2025, reflected acetaminophen - codeine tablet (pain reliever) 300-30 MG, one tablet by mouth every eight hours for pain.A record review of Resident #1's MAR, dated 12/09/2025, reflected Humalog Kwik Pen Subcutaneous Solution Pen-Injector (pre-filled disposable pen delivering rapid acting insulin to quickly lower blood sugar) 100 unit/ML before meals and at bedtime diabetes was not signed off as given by LVN A at 4:30 p.m. on 12/09/2025.A record review of Resident #1's MAR, dated 12/11/2025, reflected suprapubic catheter care every shift monitor S/P insertion site for s/s of skin breakdown, pain/discomfort, unusual odor, urine characteristics, secretions, and catheter pulling causing tension every shift was not signed off as completed by LVN A the morning shift A record review of Resident #1's MAR, dated 12/06/2025, reflected Lidocaine external patch (pain reliever that numbed the skin and block nerve signals) be applied to the hip topically one time a day for pain and removed per schedule was not signed off as given by Med Tech B at 9:59 PM on 12/06/2025.A record review of Resident #1's MAR, dated 12/06/2025, reflected Lidocaine external patch (pain reliver that numbed the skin and block nerve signals) be applied to the lower back topically one time a day for pain and removed per schedule was not signed of as given by Med Tech B at 9:59 PM on 12/06/2025.A record review of Resident #1's MAR, dated 12/11/2025, reflected air mattress check placement and function every shift was not signed off as completed by LVN A on the 6:00 a.m. shift on 12/11/2025.A record review of Resident #1's MAR, dated 12/11/2025, reflected air mattress check placement and function and air mattress to bed every shift was not signed off as completed by LVN A on the 6:00 a.m. shift on 12/11/2025A record review of Resident #1's MAR, dated 12/11/2025, reflected apply barrier cream to coccyx/sacrum and bilateral gluteal (bones at the very bottom of spine, forming the base of the vertebral column and connecting to the pelvis) every shift was not signed off as completed by LVN A on the 6:00 a.m. shift on 12/11/2025.A record review of Resident #1's MAR dated 12/11/2025 reflected suprapubic catheter care was to apply a new spit sponge(disposable oral care swabs) as needed if soiled and apply A & D ointment (a skin protectant to help relieve and heal minor skin irritations and conditions ) around stoma site (opening that collected waste) was not signed off on completed by LVN A on the 6:00 a.m. shift on 12/11/2025.A record review of Resident #1's MAR, dated 12/06/2025, reflected acetaminophen - codeine tablet (pain reliever 300-30 MG, give one tablet by mouth every eight hours for pain was not signed off given by Med Tech B at 10:00 p.m. on 12/06/2025.During an interview on 12/12/2025 at 1:20 p.m., Resident #1 stated he did not have any care concerns and received his medications and treatments timely. Resident # 1 stated he had not missed medications and treatments, and he was safe at the facility.During an interview on 12/12/2025 at 5:31 p.m., LVN A stated on 12/09/2025 he checked Resident #1's blood sugar at 4:30 p.m.PM and administered Humalog Kwik Pen Subcutaneous Solution Pen-Injector (pre-filled disposable pen delivery rapid-acting insulin to quickly lower blood sugar) LVN A did not recall the until amount of insulin given but stated he administered to Resident #1 but did not document in PCC (electronic medical record) given. LVN A stated on 12/11/2025 the morning shift he checked Resident #1's air mattress, catheter care, and placement of barrier cream to the sacrum (bones at bottom spine connecting to pelvis) was completed but the MAR was not signed off on.During an interview on 12/12/2025 at 5:41p.m., Med Tech B stated she administered Resident #1's the acetaminophen - codeine tablet (pain reliever) 300-30 MG on 12/06/2025 at 10:00 p.m. PM. Med Tech B stated she removed the lidocaine external patch from the left hip and lower back at 9:59 PM. Med Tech B stated she was not able to document right then as she was helping with other nursing duties. Med Tech B stated it was important to document (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676421 If continuation sheet Page 2 of 3 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 12/12/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete medications and treatments were given to confirm it was given. Med Tech B stated it was important to ensure medication was given to prevent pain.During an interview on 12/12/2025 at 2:27 p.m., the DON stated it was expected for Med Tech B and LVN to have signed off on the medication and treatment given. The DON stated the MAR not signed off indicated the medication or treatment was not given and could worsen symptoms.During an interview on 12/12/2025 at 6:40 p.m., the ADM stated it was expected for LVN A and Med Tech B to have signed off on Resident # 1's MAR to ensure documentation was completed. The ADM stated the MAR not signed indicated it was not completed and could cause further complications.Record review of the facility's policy, dated 10/2015, titled Documentation and Charting reflected, It is the policy of this facility to provide:1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care.2. Guidance to the physician in prescribing appropriate medications and treatments.3. The Facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident.4. Nursing service personnel with a record of the physical and mental status of the resident.5. Assistant in the development of a Plan of Care for each resident.6. The elements of quality medical nursing care.7. A legal record that protects the resident, physician, nurse and the facility.8. A source of all resident charges.Procedures:9. For Charting ErrorsA. Do not erase any error. Erasure of any type may not be made in the medical record.B. Draw a single line through the error and write the correction above the error. For electronic charting, the author of the not can strike out the entry. This will draw a line over the note without deleting it.10. Follow-Up-Notes:Documentation relating to follow-up notes should include:A. A summary of the resident's condition, until the resident is stable.B. Documentation that the resident's condition has stabilizedC. Signature and title of person recording the data. Event ID: Facility ID: 676421 If continuation sheet Page 3 of 3