Inspection·September 22, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm asthma, sleep apnea, and her heart not working very well. She stated she was dependent on staff to put water in the water chamber for her. A policy on CPAP use was not made available prior to end of survey. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676426 If continuation sheet Page 2 of 6 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 676426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation - Fort W 4240 Golden Triangle Boulevard Keller, TX 76244 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that residents who were unable to care out activities of daily living received the necessary services to maintain good grooming and personal hygiene for two (Residents #25 and #185) of 29 residents whose care was reviewed for resident rights in that: Residents Affected - Some The facility failed to provide Residents #25 and #185's with bathing assistance. This failure could place residents, dependent on staff for bathing, at risk of their needs not being met and contributing to poor self-esteem. Findings included: Review of Resident #25's EHR revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia, history of alcohol abuse, depression, difficulty in walking, and unsteadiness on feet. Review of Resident #25's MDS, dated [DATE], revealed a BIMS score of 12 indicating moderately cognitively impaired. His Functional Status indicated he required supervision with bathing and walking, but he was independent in all of his other ADLs. Review of Resident #25's care plan, dated 06/02/22, revealed he was at risk for ADL self-care performance related to unsteadiness on his feet and dementia with an intervention to encourage the resident to participate to the fullest extent possible with his daily care. Review of Resident #185's EHR revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, heart failure, asthma, sleep apnea, morbid obesity, and muscle weakness. Review of Resident #185's MDS, dated [DATE], revealed a BIMS score of 15, indicating she was cognitively intact. Her Functional Status indicated she required the assistance of two people with all of her ADLs except eating. Her Bowel and Bladder assessment indicated she was always incontinent of urine and bowels. Her Active Diagnoses indicated she was Medically Complex with multiple medical conditions. Skin Conditions indicated no skin conditions, no pressure ulcers. Review of Resident #185's care plan, dated 8/26/22, revealed she was at risk of altered cardiovascular status related to her congestive heart failure, and ADL self-care deficit related to impaired mobility and obesity, with interventions related to bathing requiring extensive assistance of 1-2 people and a goal of showering as scheduled or necessary. Observation on 09/20/22 at 10:50 AM of Resident #185 revealed a strong odor of old urine and body odor about her. Her hair was unkempt and dirty. OT D was at the resident's bedside to take the resident to therapy but was unable as the resident was not ready. The resident stated she needed to be cleaned up before going to the gym. Observation of the resident's brief, after OT D removed the brief, revealed it was heavily soaked. Observation of the bed linen under Resident #185 revealed large rings of urine on both the draw sheet and the fitted sheet. The resident's back and legs had deep wrinkle marks from the wrinkles in her linen. The resident had superficial scratches to her arms, legs, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676426 If continuation sheet Page 3 of 6 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 676426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation - Fort W 4240 Golden Triangle Boulevard Keller, TX 76244 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and abdomen. The resident stated the scratches were from her scratching at her skin. No obvious open wounds were noted. The resident's nasal CPAP was on the floor and the water chamber was empty. Interview on 09/20/22 at 10:50 AM, Resident #185 stated she had not had her brief changed since the prior evening, and she was wearing the same shirt that she had worn the previous day. She stated staff never checked on her at night, even when she pushed the call light. She stated staff would say they would be right back and then never returned. She stated she had not been bathed since she was re-admitted on [DATE], and she could not recall the last time she was bathed before she went to the hospital on [DATE]. Resident #185 stated she knew she was a lot of work to bathe, and it seemed like the facility did not have enough CNAs to bathe her very often. Resident #185 stated she would like to be bathed three times a week due to the fact that she sweated a lot. The resident stated she itched all over because she had not been bathed and her brief not being changed very often. She denied any skin breakdown, just irritation. Interview on 09/20/22 at 10:50 AM, OT D confirmed Resident #185 was wearing the same shirt from the previous day when she worked with her. OT D stated cleaning the residents and getting them ready for therapy was not in her job description, but therapy staff had to do it on a regular basis if they wanted to do any therapy with the residents. She stated waiting on the CNAs or nurses to get the resident ready would take up too much time in the day, and they would not be able to accomplish any therapy. She stated therapy staff would sometimes incorporate some therapy into the process of getting them ready for the gym, but it was not optimal therapy. OT D was observed to have spent 30 minutes getting the resident cleaned up and ready for the gym. Observation on 09/20/22 at 11:45 AM of Resident #25 revealed his hair was unkempt and dirty, his mustache and beard were unkempt as well. The resient's clothes were clean and there was no obvious body odor noted. Interview on 09/20/22 at 11:45 AM, Resident #25 stated he had not been showered in at least a week, if not longer. He stated he was lucky if he got a shower once a week. He stated he had body wash in his room that he used to wash up in the bathroom sink so he did not stink. He stated he sweated a lot because he worked with physical therapy daily, and it was hard work. Resident #25 stated he only needed staff to get him towels and let him know when the shower room was available because he could do the rest on his own. He stated bathing was not an issue when he was in another room that had a shower, but now he was in a room without a shower and had to use the shower room down the hall. He admitted to refusing a shower once because he was too tired, but staff never came back to ask again. He stated if he refused a shower he was out of luck until the next week when they came around again. Review on 09/20/22 of the facility's Shower Log binder for the month of September 2022 revealed Resident #185 was scheduled to bathe on Tuesday, Thursday, and Saturdays on the 2:00 PM-10:00 PM shift. She had a bed bath on 09/01/22 and on 09/20/22. Resident #25 was scheduled to bathe on Tuesday, Thursday, and Saturdays on the 2:00 PM-10:00 PM shift. He had a shower refusal on 09/12/22. There was no other documentation of bathing. Interview on 09/21/22 at 11:50 AM, Resident #185 stated she had been showered the previous evening, had her shirt changed, and her linen changed. Interview on 09/21/22 at 12:00 PM, Resident #25 stated he had been taken to the shower room the previous evening. He stated the facility either brought in more staff, or the staff were doing their jobs for once because everyone was getting bathed or showered the previous evening. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676426 If continuation sheet Page 4 of 6 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 676426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation - Fort W 4240 Golden Triangle Boulevard Keller, TX 76244 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 09/21/22 at 1:40 PM. LVN E she stated it was important that residents were showered or bathed on a regular basis because if they were not it was neglect. She stated she checked the shower sheets the CNAs turned in before she signed them so that she knew who refused showers. If she saw a resident that looked like they had not been showered, she would ask them how long it had been. She stated if the shower sheet was not in the binder, the resident had not been showered. She stated she would not be surprised that there were residents with no shower sheets in the binder. She stated she was responsible for ensuring the residents on her hall were showered on their days, but she relied on the CNAs letting her know who had and had not been showered. Interview on 09/21/22 at 1:51 PM, CNA F stated it was important to the resident's self esteem to be showered or bathed on a regular basis, and it also helped prevent sores and skin breakdown. If a resident refused a shower, she would ask them 2-3 more times that day before documenting the refusal. She stated she reported all refusals to the nurse when she handed over her shower sheets. If a resident wanted to wait to a later time to shower, she would let her relief know. She stated if the resident had a shower, it would be documented on a shower sheet in the shower book; no sheet meant no shower. Interview on 09/21/22 at 1:55 PM, CNA G stated it was important for residents to be showered regularly to prevent skin breakdown and body odor. She stated there was a schedule in the shower book that told them who needed to be showered that day, and they filled out a shower sheet when they were done. If a resident refused to shower or bath repeatedly, she would notify the nurse so she can see why they are refusing. She would also ask the resident 3-4 times before she documented the refusal. Interview on 09/22/22 at 11:30 AM, OT A stated she encountered, on a daily basis, residents that were not ready for therapy when she arrived to take them to the gym. She stated the residents were either not dressed, not out of bed, or needed their briefs changed. She stated she would do it herself because waiting on a CNA or nurse to come do it would take up too much time in her day, and she had a lot of residents to work with every day. She stated it could take up to 30 minutes to get a resident ready for therapy, depending on how much assistance they required. Interview on 09/22/22 at 11:35 AM, PTA B stated he worked as needed at the facility, but he frequently had to wait up to 30 minutes for a resident to be ready for therapy. He stated it depended on how much staff there was and who was working. He did not help the residents get ready, he would notify the nursing staff, and then come back to check on the resident later. Interview on 09/22/22 at 11:40 AM, PTA C stated she usually had to help a resident get ready for therapy 2-3 times a day which could delay her by 10 minutes or more. Interview on 09/22/22 at 2:10 PM, the ADON stated it was important that the residents were bathed on a regular basis for many reasons, dignity, cleanliness, and to prevent skin breakdown. She did not know why there was little to no documentation of residents being bathed. She stated she was surprised to hear that residents were complaining they were not being showered but once week or less. She was surprised that residents requiring more assistance with bathing were the ones with little or no documentation of baths being done. She was surprised that residents that had showers documented stated they had not been showered and that residents that had shower refusals documented, denied refusing a shower. She stated she, or the DON when they had one, were ultimately responsible for ensuring the residents were being kept clean. The facility did not provide a policy on resident bathing or hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676426 If continuation sheet Page 5 of 6 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 676426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation - Fort W 4240 Golden Triangle Boulevard Keller, TX 76244 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the facility provided food that was palatable, for one of one observed meal reviewed for dietary services. Residents Affected - Some The facility failed to serve food that had a palatable texture during the lunch meal on 09/21/22. This failure could affect residents by placing them at risk of weight loss, altered nutritional status, and a diminished quality of life. Findings included: Review of the facility's menu on 09/21/22 revealed the planned lunch consisted of buttermilk ranch chicken, parslied buttered pasta, seasoned green beans, blueberry cobbler, and a beverage. Observation of the lunch meal on 09/21/22 at 12:39 PM revealed the chicken was very dry, bland, and tough to chew. The butter noodles were mushy and overcooked and flavorless. The green beans also did not have any flavor. A confidential interview with 11 alert and oriented residents revealed they all had the chicken option for lunch and stated it was terrible. They stated the meat was dry and some residents said they were not able to eat it. The residents said the noodles and green beans were tasteless and not seasoned. They further stated they believed they were having a high turnover rate in the kitchen, and the food quality kept getting worse as a result. Their concerns had been mentioned to the dietary managers in the past but they felt like they were not being heard. Review of an undated grievance on 09/22/22 reflected the following: Dietary moving forward please cook vegetables and pasta to an al dente state and place them on the steam table to continue cooking to perfection and not a bowl of mush An interview on 09/22/22 at 1:13 PM with the Interim Dietary Manager revealed she had been helping at the facility for about two weeks and would be there until the dietary manager position was filled. She stated she did not taste the chicken lunch meal the day prior, 09/21/22, but cooked it in ranch seasoning and did not notice it was dry. The Interim Dietary Manager also stated she added alfredo sauce and did not know why they were flavorless and during the time she had been at the facility she had not had any complaints from the residents. Review of the facility's policy and procedure titled Food Preparation reviewed on 04/2022 reflected the following: Policy Food is prepared by methods that conserve nutritive value, flavor, and appearance. The food that is served to the residents is palatable, attractive FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676426 If continuation sheet Page 6 of 6