Inspection·November 16, 2023

F 0558 reach their call light by placing it within their reach when you are in their room. Level of Harm - Minimal harm or potential for actual harm In an interview on 11/16/23 at 9:37 AM with the DON revealed all staff were responsible for ensuring a resident's call light was within their reach. The DON said the purpose of having a call light within reach of the resident was so that they could utilize it. The DON said the concern with not having a call light within reach of the resident was that they might not be able to utilize it. Residents Affected - Few Review of the facility's policy titled Call Light/Bell, revised 08/03/21, reflected: .4 .Place the call device within resident's reach before leaving room [sic]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676426 If continuation sheet Page 2 of 11 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 11/16/2023 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a comprehensive, accurate, standardized reproducible assessment for 1 (Resident #39) of 7 residents reviewed for comprehensive assessment. The facility failed to include Resident #39's lack of dentures and difficulty in eating in her comprehensive assessment. This failure could place the resident at risk of malnutrition and weight loss. Findings included: Review of Resident #39's undated admission Record revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia, emphysema, and cognitive communication deficit. Review of Resident #39's quarterly MDS, dated [DATE], revealed a BIMS score of 14, indicating she was cognitively intact. Her Functional Status indicated she required limited assistance with her ADLs. Her Dental Status did not note any broken or loosely fitting dentures. Review of Resident #39's care plan, dated 10/20/23, revealed she was at risk for constipation related to diminished appetite. She was at risk for nutritional problems related to a history of anorexia. She was not care planned for her missing lower dentures which caused difficulty in eating some foods. Review of Resident #39's Social Work notes revealed a note on 11/01/23 by the Social Worker: Referral to (xxx) Dental per resident request for denture evaluation. Resident reports bottom dentures were lost when she went into hospital years ago. Review of Resident #39's weight history revealed her weight fluctuated a few pounds up and down month to month, but overall no weight loss was appreciated. Interview on 11/14/23 at 10:17 AM Resident #39 stated she had no lower dentures, she had been without them for quite a while. Resident #39 stated she had gone to the hospital at one point and her dentures disappeared, she did not know if they had gone missing at the hospital or at the nursing home. Resident #39 stated it was hard to eat some of the tougher foods like meat or pizza without her lower dentures, and usually the staff was good about getting her something different to eat if she asked. Resident #39 stated she had mentioned her need for dentures to the Social Worker but was unsure what was happening to get her dentures. Interview on 11/15/23 at 2:31 PM the Social Worker stated Resident #39 was placed on the dental list on 11/01/23, and she had sent the consent form to the resident's responsible party to be signed and returned. The Social Worker stated she did not know why Resident #39 had not been assessed for a mechanical soft diet that would give her softer foods to eat. The Social Worker stated she would follow up with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676426 If continuation sheet Page 3 of 11 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 11/16/2023 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 0636 Level of Harm - Minimal harm or potential for actual harm dietary, and also with the resident's responsible party to have the consent returned in time for Resident #39 to see the dentist on his November visit. Interview on 11/16/23 at 2:30 PM the Administrator stated the Interdisciplinary Team and the DON was ultimately responsible for comprehensive assessments and care plans being up to date. Residents Affected - Few Interview on 11/16/23 at 2:40 PM the DON stated she was unaware of Resident #39's need for lower dentures, she stated the resident had not had lower dentures for as long as she new. The DON stated the Social Worker had never mentioned it to her or the Interdisciplinary Team. The DON stated she would follow up on the dentures and a possible mechanical soft diet. The DON stated the Social Worker was responsible for updating comprehensive assessments and care plans and she did not know why her dental issues had not been added to the care plan Review of the facility's policy Comprehensive Person-Centered Care Planning, revised January 2022, reflected: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychological needs that are identified in the comprehensive assessment #6- The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676426 If continuation sheet Page 4 of 11 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 11/16/2023 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to use the services of a Registered Nurse for at least eight consecutive hours a day, seven days a week in the facility for 18 (08/12/23, 08/13/23, 08/19/23, 08/20/23, 08/26/23, 09/09/23, 09/17/23, 09/30/23, 10/01/23, 10/07/23, 10/08/23, 10/14/23, 10/15/23, 10/21/23, 10/29/23, 11/04/23, 11/11/23, and 11/12/23) of 60 days reviewed. The facility failed to have RN coverage in the facility for eight consecutive hours on 08/12/23, 08/13/23, 08/19/23, 08/20/23, 08/26/23, 09/09/23, 09/17/23, 09/30/23, 10/01/23, 10/07/23, 10/08/23, 10/14/23, 10/15/23, 10/21/23, 10/29/23, 11/04/23, 11/11/23, and 11/12/23. This failure could place residents at risk of not having their nursing and medical needs met and receiving improper care. Findings included: Review of RN C's time sheets from 08/01/23 to 11/12/23 reflected she worked the following dates and hours: 09/17/23 for 7.30 hours, 09/30/23 for 6.05 hours, and 10/01/23 for 7.02 hours. Review of RN D's time sheets from 08/01/23 to 11/12/23 reflected she worked the following dates and hours: 08/12/23 for 4.27 hours then 6.08 hours and then 2.65 hours (the hours were not consecutive), 08/13/23 for 6.12 hours then 6.90 hours (the hours were not consecutive), 08/26/23 for 6.09 hours then 6.92 hours (the hours were not consecutive), 09/09/23 for 6.27 hours then 6.90 hours (the hours were not consecutive), and 09/30/23 for 6.62 hours, 10/08/23 for 6.03 hours then 7.00 hours (the hours were not consecutive), 10/14/23 for 5.83 hours then 6.75 hours (the hours were not consecutive), 10/15/23 for 6.07 hours then 7.75 hours (the hours were not consecutive), 10/21/23 for 5.05 hours then 5.05 hours (the hours were not consecutive), 11/04/23 for 5.85 hours then 6.77 hours (the hours were not consecutive). Review of RN E's time sheets from 08/01/23 to 11/12/23 reflected she worked the following dates and hours: 09/17/23 for 6.00 hours, 10/14/23 for 6.22 hours, 10/21/23 for 7.15 hours, 10/29/23 for 5.77 hours, 11/11/23 for 6.72 hours. Review of RN I's time sheets from 08/01/23 to 11/12/23 reflected she worked the following dates and hours: 10/01/23 for 5.95 hours, 10/07/23 for 6.85 hours, and 10/14/23 for 6.17 hours. Review of RN F's time sheets from 08/01/23 to 11/12/23 reflected she worked the following dates and hours: 09/09/23 for 6.33 hours, 09/17/23 for 6.78 hours, 10/08/23 for 5.70 hours then 6.95 hours (the hours were not consecutive), 10/14/23 for 6.5 hours, 10/15/23 for 6.37 hours, 11/04/23 for 7.05 hours, and 11/11/23 for 6.20 hours. Review of RN G's time sheets from 08/01/23 to 11/12/23 reflected she worked the following dates and hours: 08/19/23 for 6.67 hours then 6.07 hours (the hours were not consecutive), and 08/20/23 for 6.07 hours then 6.35 hours (the hours were not consecutive). Review of RN H's time sheets from 08/01/23 to 11/12/23 reflected she worked the following dates and hours: 09/30/23 for 6.42 hours then 6.17 hours (the hours were not consecutive), 10/01/23 for 6.02 hours then 6.43 hours (the hours were not consecutive), 10/14/23 for 6.43 hours then 6.07 hours (the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676426 If continuation sheet Page 5 of 11 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 11/16/2023 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some hours were not consecutive), 10/15/23 6.97 hours then 5.35 hours (the hours were not consecutive), 10/29/23 for 6.63 hours then 5.23 hours (the hours were not consecutive), 11/11/23 for 6.39 hours then 6.40 hours (the hours were not consecutive), and 11/12/23 for 7.80 hours. In an interview on 11/16/23 at 11:31 AM with the HR Director revealed the facility had 12 hour shifts from 6 AM to 6 PM and 6 PM to 6 AM for nursing staff, including the RN's. The HR Director said she did not realize the RN coverage had to be consecutive because she was new to the facility. The HR Director said she reviewed the time sheets provided and noticed that the weekend RN coverage was not consecutive because of the way they staff the shifts and the RN's usually work 6 PM to 6 AM each day. In an interview on 11/16/23 at 12:56 PM with the Staffing Coordinator revealed she had been told to staff the nursing staff on 12 hour shifts from 6 PM to 6 AM and 6 AM to 6 PM. The Staffing Coordinator said she did not know nor had she been told to staff the RN's on the weekend so that they had consecutive hours instead of having a split shift where they work 6 hours from 6 PM to 12 AM one night/day, then 6 hours from 12 AM to 6 AM one morning/day. In an interview on 11/16/23 at 1:03 PM with the DON revealed the facility staffed their nurses by 12 hours shifts from 6 PM to 6 AM and 6 AM to 6 PM. The DON said the weekend RN coverage was covered by a charge nurse or if one was not available, she would come in to work herself. The DON said she knew the requirement was to have an RN on the weekends for at least 8 hours each day since she served as the RN for coverage during the week. The DON said she did not know that the weekend RN coverage had not been consecutive based on how the RN's were being scheduled in the 12 hour shifts. The DON said the purpose of having an RN in the building on the weekends for a consecutive 8 hours was to support the rest of the staff. Review of the facility's undated Procedure and Guidance policy reflected: .Facilities are responsible for ensuring they have an RN providing services at least 8 consecutive hours a day, 7 days a week .Facilities may choose to have differing tours of duty (e.g. 8 hours- or 12-hour shifts) for their licensed nursing staff. Regardless of the approach, the facility is responsible for ensuring the 8 hours worked by the RN are consecutive within each 24-hour period. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676426 If continuation sheet Page 6 of 11 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 11/16/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #2) of 8 residents reviewed for medication administration and labeling and storage. LVN A failed to observe Resident #14 take his morning medications, and there were 5 pills observed on his bedside table in his room. This failure could place residents at risk of not receiving medications as prescribed, decreased therapeutic effects of the medications, risk for drug diversion, delay in medication administration and worsening of their medical conditions. Findings included: Review of Resident #14's MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hypertension, hyperlipidemia, CVA (stroke), traumatic brain injury, anxiety disorder, depression, and dysphagia. Resident #14 had a BIMS score of 12 (cognition moderately impaired). Review of Resident #14's care plan dated 09/26/23 reflected the resident was resistive to care, refused to call for assistance with transfers, and resistant to allow staff to stay in room while taking medications. Goals included the resident will cooperate with care through the next review and will participate in care through next review date. Interventions included to allow Resident #14 to make decisions about treatment regime to provide sense of control, educate resident/family/caregivers of the possible outcomes of not complying with treatment of care, and give clear explanation of all care activities prior to and as they occur during each contact. The care plan further reflected if the resident resisted with ADLs, reassure the resident, leave and return 5-10 minutes later and try again. The care plan further reflected Resident #14 had swallowing problem related to coughing or choking during meals or swallowing medications. Observation on 11/14/23 at 10:27 AM revealed Resident #14 was sitting in his rocking chair and there were five pills on his bedside table. The resident stated the pills were from that morning and he had been educated on the importance of taking his medications and not leaving them on his table. He further stated he had taken all the pertinent pills and the ones on the bedside table were just vitamins. Observation and interview on 11/14/24 at 11:00 AM with the ADON revealed Resident #14 was not in his room and the 5 pills had been left unattended on the bedside table. The ADON was asked to identify the pills on the table, and she said they were Plavix (blood thinner), atorvastatin (treats high cholesterol), potassium, vitamin B12, and Isosorbide mononitrate (treats heart related chest pain). The ADON stated Resident #14 did not allow staff to watch him take his medications and this was an ongoing issue with the resident. The ADON said the resident would become angry and begin yelling at the staff during his medication administration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676426 If continuation sheet Page 7 of 11 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 11/16/2023 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 0755 Review of Resident #14's November 2023 Medication Review Report reflected the resident was taking the following medications: Level of Harm - Minimal harm or potential for actual harm Atorvastatin 40mg 1 tablet my mouth one time a day for high cholesterol. Residents Affected - Few Isosorbide Mononitrate 60mg by mouth one time a day for angina (chest pain). Potassium Chloride Extended Release 20MEQ give one table by mouth two times a day for supplement. Vitamin B-12 1000MCG give one tablet by mouth one time a day for supplement. Clopidogrel Bisulfate (Plavix) give one tablet by mouth one time a day for anticoagulation. Observation on 11/14/23 at 11:23 AM revealed Resident #14 was back in his room and LVN A was educating the resident on the importance of taking his medications and watched him take the 5 pills that were on his table. Interview on 11/14/23 at 3:26 PM with LVN A revealed she had given Resident #14 his morning medications and said they were allowed to leave his medications in his room as long as she continued to check every back often to make sure they were all taken. LVN A said after Resident #14 would take Tamsulosin (used to treat enlarged prostate) he would have to go to the bathroom right away so she would step away to continue passing medications. LVN A would make her way back to Resident #14's room and at times he would still be in the bathroom, or he would have a story to tell her between each medication causing to her be late passing medications to other residents. LVN A further stated she always tried to make sure the resident would take his more important medications like his narcotics or blood pressure pills before leaving the remainder of the medications with Resident #14. Interview on 11/16/23 at 1:54 PM with the ADON revealed it was normal for Resident #14 not to allow staff to stand there and watch him take his medications. The ADON stated staff were instructed to stay close to the resident's room to make sure he had taken all of his medications. The ADON stated Resident #14 had his rights and that was why they checked on the resident at various times after giving him his medications because he could be so difficult. The ADON said it was important to watch residents take their medications to treat their diagnoses. Interview on 11/15/23 at 3:57 PM with the Administrator and DON revealed Resident #14 was a very difficult resident and he refused to allowed staff watch him take him medications. They stated the resident had been educated many times about the importance of taking all of his medications, but the resident would escalate and become very upset. The Administrator and DON also said Resident #14 had his rights to refuse to have staff present to watch him take his medications and that was why the staff were instructed to continue checking often to make sure he had taken all of his medications. They further Resident #14 never left his room and the reason the medications had been left unattended (11/14/23) was because Resident #14 was looking for the surveyor. Interview on 11/16/23 at 2:52 PM with the DON revealed watching all residents take their medications was ideal to make sure they were taking all of their ordered medications. The DON was asked what interventions had been tried for Resident #14 and she reiterated that constant education about takin his medications was being given to the resident. Interview on 11/16/23 at 2:02 PM with the Physician revealed they had talked to Resident #14 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676426 If continuation sheet Page 8 of 11 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 11/16/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm numerous times about keeping his medications at his bedside, but the resident will become angry. The Physician said the ADON had instructed the nursing staff to make sure they watch Resident #14 take his medications. She stated it was important for staff to watch residents take their medications to ensure the residents were getting the therapeutic dose to treat their diagnoses. Residents Affected - Few Review of the facility's Administration of Medications policy, dated July 2017, reflected the following: It is the policy of this Facility, medications shall be administered as prescribed by the resident's physician, nurse practitioner, physician's assistant FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676426 If continuation sheet Page 9 of 11 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 11/16/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 2 of 3 staff (Cook J and [NAME] K) and one of one kitchen reviewed for kitchen sanitation in that: 1. [NAME] K failed to store, serve, or process foods in a manner to prevent contamination. 2. [NAME] J failed to properly wear a hair restraint while in the food preparation area. These failures could place residents at risk for food contamination and foodborne illness. Findings included: 1. Observation on 11/15/23 at 10:50 AM, of the kitchen's steamtable, revealed the far left compartment had a few inches of water in it as well as food particles which included 7 small pieces of what appeared to be meat and eggs. The entire steamtable compartment was covered in food particles and the water was not clear and had a brown/yellow tint to it. This steamtable compartment and others next to it already had containers of covered food in them to be served during lunch. Observation on 11/15/23 at 11:02 AM, of the kitchen's steamtable, revealed [NAME] K placed a container of cooked cut up beef pieces in the far left steamtable compartment without cleaning it. The compartment still had all the food particles in it. Observation on 11/15/23 at 11:26 AM revealed all the kitchen's steamtables compartments had food particles in them and the water had a brown/yellow tint to it. The third steamtable compartment from the left side had a dark brown film to it along the edge of the pan at the top of the water line. [NAME] K had placed the cut up beef pieces, cooked vegetables, and prepared mashed potatoes in each of the steamtable compartments without cleaning them. In an interview on 11/15/23 at 10:50 AM with [NAME] K and the DM revealed the night shift staff were supposed to clean the steamtable compartments twice per week usually. [NAME] K and the DM were not sure the last time the steamtable compartments were cleaned. The DM said the night shift staff signed off on the posted schedule when they cleaned the steamtable compartments. [NAME] K and the DM both looked into the steamtable compartments and acknowledged there were food particles in them and the water had a brown/yellow tint to it in each compartment. [NAME] K and the DM said they thought something must have been wasted (meaning food was spilled) in the compartment from a previous meal service. [NAME] K and the DM said the steamtable compartments should be cleaned and not have food particles in them. [NAME] K and the DM said the steamtable compartments were not cleaned before putting the cooked cut up beef pieces, cooked vegetables, and mashed potatoes on the line in the steamtable compartments. Review of the schedule posted in the kitchen titled Cleaning Schedule for November 2023 revealed the last time the steamtable compartments were cleaned was on 11/10/23. In an interview on 11/15/23 at 12:31 PM with the DM revealed there was not any time to clean the steamtable compartments between the meal services from breakfast to lunch which was why the night (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676426 If continuation sheet Page 10 of 11 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 11/16/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm shift staff were responsible for cleaning them. The DM said [NAME] K was also responsible for not putting cooked food on the line when the steamtable compartments were dirty with food particles in them. The DM said the purpose of having clean steamtable compartments was so that there would be a clean place to put cooked food ready to be served to the residents. The DM said if the dirty water got into the cooked food, it could contaminate it. Residents Affected - Some Record review of the facility's policy, revised 10/22, and titled Dietary Services reflected: 6. Proper Food Handling .V. Steam tables .3) Must be kept in clean and sanitary condition through regular cleaning. Review of the Federal Food Code 2022 reflected: 4-602.11 Equipment Food-Contact Surfaces and Utensils .3) Containers in serving situations such as salad bars, [NAME], and cafeteria lines hold READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is maintained at the temperatures specified under Chapter 3, are intermittently combined with additional supplies of the same FOOD that is at the required temperature, and the containers are cleaned at least every 24 hours. 2. Observation on 11/14/23 at 9:10 AM with [NAME] J revealed he had facial hair and was walking through the kitchen without a beard restraint. [NAME] J exited the kitchen and put on a beard restraint in the hallway. In an interview on 11/14/23 at 9:11 AM with [NAME] J revealed he was in the back of the kitchen washing dishes and had been told he was not required to wear a beard restraint unless he was handling food. [NAME] J said he did not have one on when he was walking through the kitchen and had just started recently wearing them. [NAME] J said he did have a beard with facial hair. [NAME] J said the purpose of wearing a beard restraint was to keep hair out of the food. In an interview on 11/15/23 at 12:31 PM with the DM revealed [NAME] J should have been wearing a beard restraint in the kitchen and had access to them at all times. The DM said [NAME] J had been told before that he was required to wear one at all times while in the kitchen, even when he was washing dishes. The DM said the purpose of having the beard restraint for those with facial hair was to keep hair from falling in the food. Record review of the facility's Dietary Services policy, revised October 2022, reflected: 4. Personal Hygiene, A. Proper attire for food handlers should include a hair covering (hair nets or caps) .Moustaches and sideburns must be kept trimmed. Beards must be covered. Record review of the Federal Food Code 2022 reflected: 2-402.11 Effectiveness. (Hair Restraints) 1. Code of Federal Regulations, Title 21, Sections 110.10 Personnel. (b) (1) Wearing outer garments suitable to the operation (4) Removing all unsecured jewelry (6) Wearing, where appropriate, in an effective manner, hair nets, head bands, caps, beard covers, or other effective hair restraints (8) Confining .eating food, chewing gum, drinking beverages or using tobacco and (9) Taking other necessary precautions FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676426 If continuation sheet Page 11 of 11