Inspection·May 25, 2023

F 0689 Level of Harm - Immediate jeopardy to resident health or safety fracture will resolve without complication by review date. Interventions: Provide activities that promote exercise and strength building were possible Room assignment close to the nurse's station. Therapy consults for strength and mobility. Record review of the facility Incident by Incident report, from 05/25/22 - 05/25/23, revealed Resident #1 eloped on 05/12/23. Residents Affected - Few Record review of the facility's Incident Report, dated 05/13/23, reflected the facility received a call from staff at a restaurant located 0.4 miles away from facility on the same side of the road that they may have one of our residents in their establishment. Facility staff went to the restaurant and identified [Resident #1]. [Resident #1] had sustained a ground level fall and was complaining of left hip and leg pain. EMS was present and transported [Resident #1] to the hospital for evaluation and treatment. Facility staff had last visualized Resident #1 in the facility at approximately 2230 hours [10:30 PM] ambulating in the hallway near her room after she had received her last scheduled medication for the day. It is believed that Resident #1 had exited the facility through the front door. The facility doors are unlocked while the receptionist is present and locked via keypad code at the end of the receptionist's shift. Record review of Resident #1's hospital record, dated 05/16/23, revealed Resident #1 admitted on [DATE], with the reason for admission identifed as a fall. The hospital record reflected Resident #1 was diagnosed with a closed fracture of the neck of her left femur. Resident #1 was discharged on 05/16/23. Record review of Resident #1's Elopement Risk Assessment/Wander Data Collection completed on 02/12/23 indicated Resident #1 had a diagnosis of dementia, and she could ambulate independently or with supervision. Resident #1's mental status was alert and oriented. Resident #1 had no history of elopement in the last 6 months, and she made statements about desire to leave the facility. Resident #1 had not exhibited wandering behavior but had a history of wandering. Resident #1 was at low risk for elopement and wandering. Record review of Resident #1's Elopement Risk Assessment/Wander Data Collection completed on 05/13/23 indicated Resident #1 had a diagnosis of dementia and Alzheimer's disease (brain disorder that slowly destroys memory and thinking skill), and she could ambulate independently or with supervision. Resident #1's mental status was intermittent confusion. Resident #1 had one episode of elopement history in the last 6 months, and the resident made statements about the desire to leave the facility. Resident #1 wandered, was aimless with potential to go outside, and had active exit-seeking behavior. Resident #1 was at high risk for elopement and wandering. Record review of progress note, documented by LVN A on 05/13/2023 at 1:37 AM, reflected: Late Entry: Call was received to facility by the nurse on 400/500 hall the person on the end of the line was asking if this is the home of [Resident #1] inform the nurse that resident was at the restaurant, she arrived and fell. This nurse drove to the restaurant and found resident sitting on the chair surrounded by restaurant staff, customer and EMT. Upon arrival the EMT confirmed resident name and date of birth with this nurse, nurse confirmed information. This nurse assessed resident, she was alert and oriented able state name, date of birth , notice that resident was having hard time putting left leg down, resident confirm that she was in pain. Resident couldn't get up, EMT load resident in the ambulance and took resident to the hospital. Observation and interview on 05/25/23 at 9:30 AM revealed Resident #1 lying in bed and watching (continued on next page) 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 05/25/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few television. Resident #1 stated she was doing well. Resident #1 was not a good historian and could not recall leaving the facility or having a fall. Resident #1 denied having any pain. Interview on 05/25/23 at 11:37 AM with CNA B revealed she was the assigned CNA on 200 Hall on 05/12/23. CNA B stated her shift ended at 10:00 PM. CNA B stated Resident #1 could ambulate on her own before the elopement incident, and the resident would walk around the facility all the time. She stated Resident #1's usual routine would be walking around the facility until she would get tired and would go back to her room. CNA B stated she could not recall when the last time she had last seen Resident #1 on 05/12/23; however, Resident #1 was walking the halls. CNA B stated Resident #1 did not have an elopement history. She stated Resident #1 would mention wanting to go home; however, the resident had not attempted to leave. Interview on 05/25/23 at 1:21 PM, with LVN A, by phone, revealed she was the nurse on duty for the night of 05/12/23. LVN A stated she was assigned to 100 and 200 Hall. She stated Resident #1's day-to-day behavior was to wander the halls. She stated Resident #1 was known to walk the halls even during the night, and once she was tired the resident would go to bed. She stated Resident #1 had wandering behaviors; however, the resident had not attempted to leave before. She stated Resident #1 eloped during her shift. She stated the last time she observed Resident #1 was around 10:30 PM, she stated the resident was coming from 400 Hall and going towards 600 Hall. LVN A stated the facility had a receptionist until 8:00 PM. LVN A stated the receptionist was responsible for locking and unlocking the entrance doors, she stated they had the code. She stated between 11:45 PM and midnight (12:00 AM) she received a call from a nearby restaurant asking her if Resident #1 was a resident at the facility. She stated she looked around the facility and could not locate Resident #1. She stated she rushed to the restaurant that was about 2-3 minutes away by car. She stated when she arrived at the restaurant Resident #1 was sitting on a chair and was drinking water. She stated Resident #1 verbalized being okay. LVN A stated she assessed the resident, and the resident stated she was in pain. LVN A stated EMTs were on scene already, and they transported Resident #1 to the hospital because she was not able to walk and complained of pain to her left hip. LVN A stated the restaurant staff informed her Resident #1 had a fall. LVN A stated Resident #1 exited the facility through the front entrance door because when she was leaving the facility to go to the restaurant, the front entrance door was unlocked. LVN A stated she was unaware the front door was unlocked until after the incident. She stated she did not hear any alarms going off. Interview on 05/25/23 at 1:36 PM with Receptionist F revealed she worked the day of 05/12/23. She stated her shift was from 2:00 PM-8:00 PM. She stated it was the receptionist's responsibility to lock and unlocked the front entrance door. Receptionist F stated the receptionist had the codes to the door. She stated the front door had two different codes: one code to unlock and lock the door, and the second code was used to exit the front door once it was locked. She stated the night of 05/12/23 when her shift ended, there were still visitors at the facility, so she provided the code to the night nurse whom she believed was RN C or LVN D, so they could let the visitors out. She stated she provided the code that allowed people to exit the facility once the door was locked. Receptionist F stated she locked the door before she left the facility. Receptionist F stated this was the first time Resident #1 had ever eloped. She stated they had not had any previous elopement incidents. Interview on 05/25/23 at 1:43 PM with RN C revealed she worked the night of 05/12/23. She stated her shift started at 10:00 PM; however, she arrived around 9:50 PM. RN C stated she never observed Receptionist F because she was already gone. RN C stated when she arrived at the facility the front door was locked. She stated she was unable to open the front door and called someone to open it for her. RN C stated she observed Resident #1 walking the hallways as her usual routine. RN C stated she (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 05/25/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few could not remember what time she last saw Resident #1. RN C stated between the times of 11:30 PMbefore midnight LVN A notified her a restaurant had contacted the facility to notify them Resident #1 was there. RN C stated she and LVN A drove to the restaurant where they observed Resident #1 seated on a chair in the company of the restaurant staff and the EMT team. She stated Resident #1 complained of pain to her left lower limb, and they made the decision to have her checked at the hospital. RN C stated when they left the facility to go to the restaurant the front entrance door was open, and no alarms were heard the entire time. She stated Resident #1 eloped through the front door. RN C stated she was never informed of any family in the facility, and she did not talk to Receptionist F. An attempt was made to contact LVN D by phone on 05/25/23 at 1:49 PM; however, the phone call was unsuccessful. Interview on 05/25/23 at 2:02 PM, the ADON stated she was off duty on 05/12/23. The ADON stated she was made aware of the elopement incident on Monday, 05/15/23. The ADON stated during the facility investigation it was determined Resident #1 eloped from the facility at approximately 11:00 PM via a secured door leading to the main road. The front door of the facility was unlocked because no alarms were heard. The ADON stated there was a miscommunication between Receptionist F, who worked from 2:00 PM-8:00 PM, and the nurse on duty, LVN D. She stated there were still visitors at the facility, and Receptionist F provided the code to LVN D. The ADON stated Resident #1 had a fall and sustained a left hip fracture. She stated Resident #1 was known to wander around but had never attempted to exit the facility before. The ADON stated Resident #1 was easy to redirect. The ADON stated following this incident they trained all staff on missing persons/elopement. She stated they all trained the nurses on conducting a midnight census head count before and after their shift and checking all the doors to ensure they were locked. The ADON stated they changed the front door code so only one code had to be used, and they provided walkie talkies on each nurse's station for communication. Additionally, they implemented random elopement drills and would continue for the drills for the next 4 weeks. Interview on 05/25/23 at 2:12 PM, the DON stated she received a call on 05/13/23 at 12:15 AM from LVN A who informed her Resident #1 had eloped from the facility and was reported to be at a restaurant. The DON stated LVN A went to the restaurant and Resident #1 had complained of pain and EMTs were already on the scene so they took Resident #1 to the hospital. The DON stated during the facility investigation it was determined Resident #1 eloped from the facility at approximately 11:00 PM via the main entrance front door. She stated the front door of the facility was unlocked because no alarms were heard. The DON stated there was a miscommunication between the Receptionist, who worked from 2:00 PM-8:00 PM, and the nurse on duty. She stated there were still visitors at the facility around 8:00 PM, and the Receptionist provided the code to LVN D. The DON stated the front door had two different codes: one code unlocked and locked the door, and the second code was used to exit the front door after it was locked. The DON stated following the incident they trained all staff on missing persons/elopement. The nurses were trained to conduct a midnight census head count before and after their shift and to check that all the doors were locked. They also changed the front door code so only one code had to be used. The DON stated they provided walkie talkies on each nurse's station for communication, and they implemented random elopement drill and would continue the drills for the next 4 weeks. The DON stated they completed an elopement assessment on all current residents. The DON stated Resident #1 had been a resident since 2020 and had not had any elopement incidents. The DON stated Resident #1 had wandering behaviors but had not attempted to leave before. She stated Resident #1 currently could not walk due to her fracture; however, once the resident became more mobile and upon assessment if the resident showed any exit-seeking behaviors, they would find an alternative placement and would transfer Resident #1 to a secure unit. (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 05/25/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview on 05/25/23 at 2:39 PM with CNA E by phone revealed she was the assigned CNA for 200 Hall on 05/12/23. CNA E stated her shift started at 10:00 PM. CNA E stated Resident #1 was known to wander around the facility but did not attempt to leave. CNA E stated the night of 05/12/23 Resident #1 was walking around the halls, she stated she was assisting other residents and the last time she had seen Resident #1 was between 10:30 PM and 11 PM walking on the hall. CNA E stated the entrance door was always locked and they needed a code to unlock it. CNA E stated she did not know the code to unlock the door, she stated the receptionists were responsible for locking and unlocking the doors. CNA E stated Resident #1 did not have an elopement history but she was known to wander the facility. CNA E stated Resident #1 was easy to redirect. CNA E stated facility was notified that Resident #1 was at a nearby restaurant. Interview on 05/25/23 at 4:47 PM with the Maintenance Director revealed the morning of 05/13/23 he received a call from the DON notifying him Resident #1 had eloped. The Maintenance Director stated he came to the facility that night and the door was functioning correctly. The Maintenance Director stated there was a miscommunication between the receptionist and LVN D regarding the door code and the door was left unlocked. The Maintenance Director stated he had been conducting random elopement drills with the staff which consisted of picking a volunteer resident and hiding that volunteer resident in the facility . He stated the nurse on that hall must conduct a head count on the residents on the hall and if someone was missing, they must call Code Pink which was the code for a missing person. The Maintenance Director stated all the staff must meet at the nurse's station where the Code Pink was called and they all got the walkie talkies and they started the search. He stated once the volunteer resident was found the staff who called the Code Pink was the only person who could call it off. He stated he would provide feedback on the staff on how to do things better. He stated the elopement drills will continue for the next 4 weeks. Observation on 05/25/23 at 5:15PM of the Maintenance Director unlocking and locking the main entrance door. Observed Maintenance Director hold the door for 15 seconds and alarms went off. This was determined to be a Past Non-Compliance Immediate Jeopardy on 05/25/23 at 3:00 PM. The DON and the ADON were notified. The DON was provided with the IJ template on 05/25/23 at 5:30PM. The facility took the following actions to correct the non-compliance prior to the survey: Record review of the following in-services dated 05/13/2023, Elopement policy and procedure, Visual/Documented census protocol, and Missing Resident/Elopement. In-service reveal all staff completed the training. Record review of the facility Midnight Census reports, starting date 05/13/2023 through 05/25/23, revealed residents head count on both shifts from 6AM-6PM & 6PM-6AM. Nurses signatures on each form were observed. Record review of the facility Emergency Preparedness Drills - Missing Person/ Elopement revealed drills were conducted by the Maintenance Director on 5/13/23 at 1:35 PM and 5/24/23 at 10 AM. Interviews on 05/25/23 from 11:30 AM through 5:20 PM with Receptionist G, Receptionist F, CNA B, CNA E, CNA H, CNA K, CNA L, CNA M, LVN A, LVN I, LVN J and RN C who work the shifts of 6:00 AM-6:00 PM and 6:00 PM-6:00 AM were able to verify education was provided to them, nursing staff were able to accurately summarize missing person/elopement policy, missing/elopement code, emergency preparedness missing person/elopement drills, and midnight census count. (continued on next page) 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 05/25/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of the facility's Elopement/Unsafe Wandering policy and procedure, revised 1.2022, reflected the following: It is the policy of this facility to provide a safe environment for all resident through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement. 1. Resident with capabilities of ambulation and/or mobility in wheelchair will have an elopement/wandering evaluation completed to determine risks for elopement and unsafe wandering on admission and with observed behaviors of wandering or attempting to elope. 3. Staff shall promptly report any resident who is trying to leave the premises or suspected or being missing to the charge nurse or supervisor to evaluate the need for further interventions. The noncompliance was identified as past non-compliance. The IJ began on 05/12/23 and ended on 05/13/23. The facility had corrected the noncompliance before the survey began. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676426 If continuation sheet Page 6 of 6