Inspection·September 11, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few resident in the hallway. The nurse and CNA started looking for him in the rooms of 600 hall, we did not see him. This nurse called for code white alerted all the staff in the facility and we started looking for him in and out of the facility. Family called and left them a message to call the facility. The family called back later and told this nurse they will come over to the facility. Administrator was notified.Record review of Resident #1's progress notes dated 07/29/25 at 4:53 AM by Clinical Market Leader reflected: 4:50am police arrived to facility with resident in back seat. Resident able to stand and transfer to wheelchair and brought into facility for assessment by charge nurse. Family also arrived behind police and notified of return to facility. Police notified this writer that EMS would arrive shortly to assess him as this was their protocol. Resident alert and denies pain, water in hand, assisted to his room by nurse and family.Record review of the facility's Provider Investigation Report, completed by the Administrator on 08/05/25, reflected the following: Incident date: 07/28/25, Time of Incident: 8:00 PMDescription of the Allegation: Resident missing from facility Assessment Date: 07/29/25; Time: 4:55 AM;Charge nurse completed head to toe assessment upon resident return on 7/29/25 @ apprx. 4:55 a.m - no injuries notes, resident mood was pleasant and friendly. EMS arrived at apprx. 5:10 a.m. (per PD policy). Completed assessment as well - no concerns. Vitals within normal limits. Attending physician assessed at apprx. 10:30 a.m. no injuries notes - suggested precautionary CBC normal results - Skin assessment completed during shower by c.n.a. no issues noted. Provider Response: The facility initiated missing resident protocol. Implementing search efforts to include inside facility, outside the facility and an extensive search of the surrounding area by vehicle, on foot, air search and K9 unit. Facility completed a visual census check of all residents in the facility. The facility informed the medical director-administrator-Interim DON-Family-[Name] PD of missing resident. Family reviewed camera footage to establish at timeline and verify description. Facility initiated interviews with all staff working at the time of the incident. Facility reviewed elopement risk assessments for all residents on 07/28 & 07/29/2025. Interventions and care plans were reviewed and modified as appropriate. Facility initiated education and in servicing related to elopement/missing residents as well as abuse/neglect. Facility conducted on site elopement drills for both shifts. Facility initiated education and implemented documented census reconciliation process to be completed at the onset of each shift and again at 2359. Facility adjusted camera system to provide visual monitoring of the front door at each nurse's station. Facility initiated walking rounds to include lobby area during the 6p-6a shift. Installation of wader guard sound box with flashing lights at each nurse's station in addition to the exiting one at the front door. Facility is in the process of installing a camera outside of the front entrance. Charge nurse was suspended pending investigation later terminated. Upon resident return Head to toe assessment X 2 - no injuries noted. No new orders. Family notified upon exit and return - medical director notified upon exit and return. Resident placed 1-1 observations - resident d/c to another SNF with secure area on 7/29/25. Investigation Summary: After completing staff interviews and reviewing video footage it was determined the res was observed to be on 600 Hall walking along side charge nurse. At apprx. 7:40 p.m. resident walked away from the nurse out of camera view as she continued med pass on 600 hall. At apprx 7:51 p.m. res [resident] was seen to be in the front foyer walking around. At apprx. 7:54 p.m. resident was seen on camera following a Hispanic female out the front door. The nurse stated at apprx. 8:00 p.m., she noticed resident was not in his room or on the 600 Hall. Elopement protocol was initiated search efforts included the inside and outside parameters of the facility as well as an extensive search of the surrounding territory. Facility staff and leadership actively engaged in the search by foot and vehicle utilizing resident photo and description. [Department Name] PD became involved in the (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 09/11/2025 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 search to include foot patrol/vehicle patrol/Helicopter search and K9 (canine) unit as well as social media alerts. Multiple family members were onsite assisting in search efforts as well communicating with facility administration sharing leads and search efforts. Resident was located in the parking lot of a nearby car dealership. [Department Name] PD returned the resident at approximately 4:55 a.m. on 7/29/25. Resident was drinking water and smiling. He appeared to have his normal demeanor. Head to toe assessment completed by charge nurse as well as EMT (per PD protocol). No injuries noted, vitals within normal range. Family arrived within minutes of his return embraced resident and assisted staff with preparing him for bed. Resident went to sleep within moments. Shower offered resident no new findings. Labs requested to be followed up at receiving facility as resident was transferred to [Facility Name] in a secure environment. Labs resulted within normal range with no new orders. During follow up conversation with the family, they agreed to resident likely related the Hispanic female he followed out the door to his spouse as she had visited earlier in the evening. Resident did wander within the facility although he had not made previous attempts to exit the facility. Family expressed gratitude and appreciation for the care that was provided to the resident.Record review of RN A's witness statement, dated 07/28/25, reflected the following: To whom it my concern, approximate @ 1900 [7:00PM] resident noted with wet pant and CNA took him to his room and cleaned him up and dressed him on green top and red pants. After he was changed resident started following this nurse while passing HS meds. At approximate 2000 [8:00PM] I noticed resident was not on hallway. Myself and the CNA started looking for him in all the rooms and bathrooms on 600 Hall. We did not locate him and at that time I called Code White. All staff in the facility started looking for him around the in and out of the facility. Family and administrator was notified. Regards, RN A. Record review of CNA B witness statement, dated 07/29/25, reflected the following: Statement of CNA B 500/600 Hall, around 7PM she noticed his pants was wet & she took him into his room & changed out his pants. When she got finished with him, he went back to the nurses. Around 8 he was with the nurse & I was with another resident that was going out & when I came out the nurse asked about him. And I said that he was with you & she told me she couldn't locate him. So, then we all was looking for him together. We could not find him inside the building, so we went outside the building & still was unable to locate him. Witnessed by CNA B.An attempt was made to contact RN A by phone on 09/11/25 at 11:30 AM; however, there was no answer. Interview on 09/11/25 at 11:36 AM with LVN C revealed she worked the night Resident #1 eloped from the facility on 07/28/25 from 6PM-6AM. She stated she was the nurse assigned to 200 Hall and a little after 7:00PM before 8:00PM she had gone to 600 Hall looking for something and she observed Resident #1 standing behind RN A. She stated at approximately 8:00 PM she was notified of the code white. She stated she stopped what she was doing and checked each of her rooms on 200 Hall before she went over to the 600 Hall. LVN C stated that night there was visitors in the building. She stated no WanderGuard alarms were heard that night. She stated everyone was notified and Resident #1 was found on 07/29/25 at around 5:00 AM. LVN C stated Resident #1 was an elopement risk because he would pace the hallways and follow people around. Interview on 09/11/25 at 2:08 PM with CNA B revealed she was the CNA assigned to Resident #1 when he eloped from the facility on 07/28/25. She stated around 7:00 PM she observed Resident #1 with RN A, she stated Resident #1 needed a brief change, so she took him to his room to change him. Once she was done changing Resident #1, Resident #1 went back to the nurse's station to be with RN A. She stated RN A was passing out medications and Resident #1 was following her. CNA B stated she continued to assist other residents and around 8:00PM RN A was calling for her. She stated RN A told her she had heard the WanderGuard alarms go off at the main entrance but did not see anyone and she turned off the alarm. CNA B stated she did not hear (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 09/11/2025 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 any alarms go off because she was in a resident room. She stated RN A asked her for help on checking on the residents and that was when RN A noticed Resident #1 could not be located. CNA B stated RN A called a code white and everyone began to search for Resident #1 inside and outside the facility. CNA B stated Resident #1 was found the following day on 07/29/25 at around 5:00 AM. She stated Resident #1 was assess and had no injuries. CNA B stated Resident #1 was an elopement risk and had a WanderGuard on. She stated Resident #1 was known to pace the hallways and follow people around the facility. CNA B stated Resident #1 was able to walk without assistance. She stated that night Resident #1 followed a visitor out the facility.Interview on 09/11/25 at 2:59 PM with the DON revealed she was on leave when Resident #1 eloped from the facility. She stated Resident #1 was known to pace the hallways and follow staff around the facility but was easily redirected. She stated she could not recall if Resident #1 would exit seek, but he would come to the front area of the facility. She stated after the elopement the facility inserviced all staff on elopement/missing person, what to do in case of an elopement and abuse and neglect. She stated elopement risk assessments and care plans were reviewed. She stated nurses are expected to print out a census and complete a resident head count at the beginning of each shift. The DON stated they also added a new WanderGuard alarm system on each nurse station with flashing lights. She stated they also added a camera at the main entrance and each nurse station surveillance monitors were added to overlook different areas of the facility. Interview on 09/11/25 at 3:10 PM with the Administrator revealed she was notified of Resident #1's elopement at around 8:40 PM. She stated she reviewed camera footage because there were some inconsistencies with what the resident was wearing. She stated camera footage revealed at 7:51 PM Resident #1 was observed following RN A, then it showed Resident #1 walking away from the nurse. She stated at 7:54 PM a visitor was walking towards the main entrance and Resident #1 can be observed following behind the visitor. The Administrator stated according to RN A she heard the WanderGuard alarms go off and the nurse went to go check but did not observe anyone at the front and deactivate the alarm. She stated RN A went back to her hall and completed a head count of her resident and that was when she noticed Resident #1 missing. She stated a code white was called and everyone began the search. She stated Resident #1 was found at 4:55 AM on 07/29/25 by the police department. She stated Resident #1 was located about 2 miles away from the facility at a local business. The Administrator stated when Resident #1 returned to the facility he was happy, a head-toe assessment was completed, and no injuries were noted. The Administrator stated Resident #1 was an elopement risk and had a WanderGuard because he would walk around the facility. She stated Resident #1 never attempted to open doors or tried to go outside. She stated the day Resident #1 eloped, the visitor he followed behind fit the description of his wife. The Administrator stated Resident #1 was probably thinking he was following his wife out. She stated after the incident all staff were in-service on elopement/missing person, abuse and neglect, completed elopement/missing person drills, a new WanderGuard alarm system was placed at each nurse's station, weekly door/WanderGuard checks completed and at beginning of each shift nurses must print out a census and complete a head count of all residents. She stated a camera was placed outside the main entrance and surveillance monitors were placed at each nurse's station. She stated elopement risk assessments were completed on all residents and care plans were reviewed. The Administrator stated Resident #1 was placed on 1:1 supervisor and then discharged on 07/29/25 to a more appropriate placement.Record review of the facility's Elopement/Unsafe Wandering policy, revised January 2022, reflected the following: It is the policy of this facility to provide a safe environment for all residents through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement. This facility is committed to promoting resident autonomy by providing an (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 09/11/2025 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 environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision and diversional programs to prevent unsafe wandering while maintaining the least restrictive environment for those at risk for elopement.This was determined to be a Past Non-Compliance Immediate Jeopardy on 09/11/25 at 4:22 PM. The Administrator and the DON were notified. The Administrator was provided with the Immediate Jeopardy Template on 09/11/25 at 4:25 PM.The facility took the following actions to correct the non-compliance prior to the abbreviated survey:Record review of the facility's Resident frequent Monitoring Tool reflected Resident #1 was placed on 1:1 supervision on 07/29/25 from 5:30 AM until he transferred at 11:30 AM. Record review of Elopement/Wandering Evaluation reflected they were reviewed and completed on Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5 on 07/29/25.Record review of Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5's Care Plans reflected care plans were reviewed on 07/29/25 to reflect them as being at risk for elopements and having WanderGuards.Record review of the facility's Elopement binders located on both nurse's stations and reception reflected pictures of residents who were at elopement risk and contained information regarding the residents.Record review of the facility Elopement Drill Drills reflected a drill was completed on 07/29/25 at 12:00PM.The facility continued to conduct random Missing Person/Elopement drills on the following days: 08/09/25 6:15 PM, 08/14/25 - 8:15 PM, 09/08/25 - 11:05 AM. Record review of facility Emergency Exit Door and Wanderguard Inspection Log forms for all exit doors reflected door checked were completed daily from 07/29/25 through 07/31/25 and then completed once a week from 08/01/25 through 09/06/25 by Maintenance Director. Record review of facility daily Census/Midnight Census print out, start date 07/29/25 through 09/11/25 reflected nursing completing head count of residents. Observation on 09/11/25 at 10:15 AM of nurses' station revealed surveillance monitors were added at each nurses' station that overlook different areas of the facility and outside the main entrance. Observation on 09/11/25 from 2:55 PM through 2:58 PM revealed main entrance WanderGuard alarm was tested with Maintenance Director. Each nurses' station has an alarm for WanderGuard, and the alarm was heard throughout the facility. When alarm goes off flashing light flashes which indicates Code White.Record review of in-services dated 07/28/25 and 07/29/25 reflected all facility staff were in-serviced on: Elopement/Missing Resident, Policy, Procedures, Elopement Book, Abuse and Neglect. Summary of Inservice: Assessment- Residents are assessed upon admission, quarterly and with any changes in condition or elopement attempts. Care Plans are updated for those that are high risk. WanderGuards - WanderGuards must have a physician order and should be changed out every 6 months. Alarms should be responded to immediately in the event a resident is attempting to exit the facility. If a resident is found missing, the employee and team will initiate the missing resident procedures as outlined in the Elopement/Unsafe Wandering Policy and Guidelines (attached) that is located in the elopement. What to do in the event of an Elopement; What to do in the event you are unable to locate your patient; What to do if you hear the alarm going. Elopement Code White, Abuse and Neglect. In-serviced on 08/07/25 reflected Wander guard - New alarm sound/flashing light at nurse's station. [NAME] light flashing and sound possible elopement. When alarm sounds staff will respond accordingly. Wander guard- all staff immediately check foyer/front door area as well outside the door. Interviews on 09/11/25 from 11:36 AM through 5:20 PM with CNA B, LVN C, ADON D, ADON E, Housekeeping F, Housekeeping G, Therapy H, Therapy I, Dietary Supervisor, [NAME] J, CNA K, CNA L, MA O, CNA P, LVN Q, LVN R, LVN S, Social Worker and Maintenance Director who worked the shifts of 6:00 AM-6:00 PM, 6:00 PM-6:00 AM revealed the facility staff were able to verify education was provided to them. Facility staff were able to accurately summarize the elopement/missing person, code (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 09/11/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete white, abuse, and neglect in-service, and where to locate elopement binders. Facility staff were able to indicate new WanderGuard alarm system were added to each nurse's station with flashing lights and elopement/missing person drills were completed. Nursing staff stated a daily/midnight census were printed and head counts were completed before shift, elopement assessment were reviewed/completed (an evaluation to determine any resident at risk of elopement), care plans reviewed for residents who were elopement risk, nurses ensure WanderGuards were checked daily to ensure they were working properly and document on the MAR, and surveillance monitors were added to each nurses station that overlook different areas of the facility. Staff indicated a surveillance camera was also added at the front entrance to provide additional oversight. Event ID: Facility ID: 676426 If continuation sheet Page 6 of 6