Health inspection·November 19, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ambulation/elimination status was chairbound/continent, no change in condition in last 14 days, gait/balance required the use of assistive devices (i.e. cane, walker, wheelchair, furniture), and took 1-2 medications (or medication classes) currently or within the last 7 days of anesthetics, antihistamines, antihypertensives, antiseizures, benzodiazepines, cathartics, diuretics, hypoglycemics, narcotics, psychotropics, sedatives/hypnotics with a medication change in the last 14 days. The focus revealed Resident #1 was at risk for falls. Interventions were Assist resident with ambulation and transfers, utilizing therapy recommendations; Determine resident's ability to transfer; Evaluate fall risk on admission and PRN; If fall occurs, alert provider; If fall occurs, initiate frequent neuro and bleedingevaluation per facility protocol; If Resident is a fall risk, initiate fall risk precautions.Record review of Resident #1's BIMS, on 9/21/2025, revealed a score of 08, which indicated Moderate Cognitive Impairment.Record review of Resident #1's Progress notes revealed an incident note that was struck through, dated 9/21/2025 at 11:55 PM, by RN A, that stated Note Text : 2100 [9:00 PM]:Heard Resident screaming for Help, Nurse went to pt room, Pt found laying on his on the floor, Assess pt, Pt transferred in bed with Hoyer lift x 3 Assist, ask Pt what Happen Pt stated am trying to Shut the door, Pt A&O x 1, unable to move Right Lower extremity c/o pain PRN Tylenol, administered. Neuro checked initiated, VS Checked WNL, 1050: Nurse went back into Pt room to check on Pt, blood noted in Foley bag, and also from Pt Penis, Dr On call called no answer,2327 [11:27 PM]: Called 911, paramedics In, Pt transported to [local hospital], Family called and Notified, DON Notified. Strike Out Reason: Incorrect Documentation. A Health Status Note entered on 9/21/2025 at 11:55 stated Note Text : 2100 [9:00 PM]: Nurse went into Pt room, Pt observed laying Supine (laying on one's back face upwards) on the floor beside the bed to the right, no call light activated at this time from pt room. Nurse Perform initial assessment, no c/o pain or distress noted, VS checked, pt able to move extremities, no swelling or discoloration noted, extremity equal, log roll pt to check pt head no bump or redness noted, insert Hoyer sling, Pt was transferred into his bed x 3 Assist, pt tolerated well, bed placed in lowest position, call light placed within pt reach, reminded pt to always use his call button, pt verbalize understanding, Neuro Check Initiated, VS Checked BP 138/80,P77,R 20,O2 98,T97.6 and continue 15 x ,2200; Resident Dr on-call notified about Pt fall, [Family Member] called phone not connecting, q30 minutes x 2,2250: Went Back into Pt room to check on Pt Neuro check ongoing, Pt c/o pain F/U complete Head to Toe Assessment done, Assess both extremities, c/o pain to right extremity, Blood Noted to Pt Foley,2327 [11:27 PM]: Paramedics 911 called, Pt sent to ER. At [local hospital], Report given to Paramedics crew, paperwork printed and given to them, [family member] called No Answer 2354 [11:54 PM]: [family member] Called and Notified. DON Notified.Record review of Resident #1's Change in Condition, dated 9/22/2025, revealed signs and symptoms identified were falls and bleeding (other than GI) that began on the night of 9/21/2025. Vital signs were considered normal and taken at 9:23 PM. Review Findings indicated this was a new onset of conditions and the symptoms or signs had gotten worse. The mental status evaluation of Resident #1 revealed increased confusion compared to the resident's baseline that was a persistent change from usual cognitive function. The functional status evaluation described the change as a fall with the fall associated with any suspected serious injury (e.g. fracture) any hip pain, or more than minor pain elsewhere. Genitourinary status evaluation revealed blood in urine described as gross hematuria with pain, fever or other signs of bleeding at other sites. Pain status evaluation revealed Resident #1 had pain and was unable to cognitively rate their pain scale. Pain was musculoskeletal in location and described as marked localized bruising, swelling, or pain over joint or bone, with or without recent fall. Exact location of pain was documented as right trochanter (hip). Date and time clinician notified was documented as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676489 If continuation sheet Page 2 of 5 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 676489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Legacy Midtown Park 8280 Manderville Lane Dallas, TX 75231 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 9/21/2025 at 11:34 PM. Resident representative notification was documented to be 9/21/2025 at 11:50 PM.Record review of Resident #1's Care Plan, closed on 10/06/2025, revealed the following significant Focus Areas and Interventions: Focus: The resident is on sedative/hypnotic therapy r/t Insomnia. Interventions: Administer sedative/hypnotic medications as ordered by physician; Monitor/document side effects and effectiveness Q-SHIFT; Monitor/Document/Report PRN for following adverse effects of sedative/hypnotic therapy: daytime drowsiness, confusion, loss of appetite in the morning, increased risk of falls and fractures, dizziness. Date Initiated: 06/20/2025 Focus: The resident has a right tibial fracture r/t Fall, s/p ORIF. Interventions: Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. Follow MD orders for weight bearing status. See MD orders and/or PT treatment plan. Monitor/document/report PRN s/sx of tibial fracture complications: Embolism s/sx (cyanosis, pain, petechiae, increased heart rate [Tachycardia], tachypnea, difficulty breathing [Dyspnea]), Infection at surgical site, Impaired mobility, Unrelieved pain. PT, OT evaluation and treatment per orders. Date Initiated: 06/20/2025 Focus: The resident is at risk for falls r/t deconditioning, right tibial fracture. Interventions: Anticipate and meet the residents' needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Date Initiated: 07/13/2025 Focus: The resident has limited physical mobility r/t Weakness, deconditioning, right tibial fracture. Interventions: The resident is non-weight bearing to RLE X 12 weeks, See physician notes/Therapy updates. Locomotion: The resident uses W/C for locomotion. Provide extensive assist x 1 staff PRN. Date Initiated: 07/13/2025 Focus: The resident has an ADL self-care performance deficit r/t recent right lower extremity surgery. Interventions: Bathing/Showering: The resident requires total assist x 1 staff per facility schedule and as necessary. Bed Mobility: The resident requires extensive assist x 2 staff to turn and reposition in bed as necessary. Bed Mobility: The resident uses an assist bar to maximize independence with turning and repositioning in bed. Dressing: The resident requires total assist x 1 staff. Eating: Provide set up assist x 1 staff to eat. Personal Hygiene: The resident requires total assist x 1 staff with personal hygiene and oral care. Toilet Use: The resident requires total assist x 2 staff for toileting. Transfer: The resident requires extensive assist x 1 staff as necessary. Date Initiated: 07/13/20252. Record review of Resident #2's admission record revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #2 had diagnoses which included Urinary Tract Infection (infection caused by bacteria entering the urinary tract [kidneys, ureters, bladder, and urethra]), Chronic Diastolic (Congestive) Heart Failure (condition where the heart muscle becomes stiff and less able to relax between heartbeats, leading to reduced filling of the heart chambers), Pain in Thoracic Spine (pain in the middle back, between the neck and the lower ribs), Muscle Wasting and Atrophy, Other Abnormalities of Gait and Mobility, Other Lack of Coordination, Abnormal Posture, Cognitive Communication Deficit (communication challenge caused by impaired thinking abilities, such as memory, thinking, or problem solving, rather than a language or speech impairment), Muscle Weakness (Generalized), Age-Related Physical Debility, Unspecified Dementia (symptoms of dementia but the specific underlying cause cannot be determined), and Restlessness and Agitation. Record review of Resident #2's admission MDS, dated [DATE], revealed functional limitation in range of motion of both sides upper extremities (shoulder, elbow, wrist, hand), and a wheelchair was normally used for mobility. Functional abilities noted Partial/moderate assistance was needed with oral hygiene, upper body dressing, and personal hygiene. Substantial/maximal assistance was noted to have been needed for shower/bathe self, lower body dressing, and putting on/taking off footwear. Resident #2 was noted to be dependent, where helper did all of the effort, for toileting hygiene. Resident #2 was evaluated to be dependent, where (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676489 If continuation sheet Page 3 of 5 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 676489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Legacy Midtown Park 8280 Manderville Lane Dallas, TX 75231 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few helper did all of the effort, for mobility of roll left and right, sit to lying, lying to sitting on side of the bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, car transfer, walk 10 feet, walk 50 feet with two turns, and walk 150 feet. Resident #2 was noted to have been always incontinent of bladder and frequently incontinent of bowel. Resident #2 was noted to not have had any falls in the last 6 months or have any fractures related to a fall in the past 6 months.Record review of Resident #2's care plan, last updated 9/17/2025, revealed the following significant Focus Areas and Interventions: Focus: The resident is at risk for falls r/t Deconditioning. Interventions: Anticipate and meet the resident's needs; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Pt evaluate and treat as ordered or PRN. Date Initiated: 09/15/2025Record review of Resident #2's BIMS, on 10/05/2025, revealed a score of 03, which included a severe cognitive impairment. Record review of Resident #2's Progress Note, dated 10/05/2025 at 4:25 AM, by LVN B, revealed during CNA rounds, resident was found on the floor lying on her left side. Resident stated she slipped and fell while attempting to go to the bathroom. Upon assessment, a skin tear was noted on left arm and bruising near left knee. Resident yelled out in pain and complained of pain to the left hip and leg while attempting to assist her with getting up. Resident remained in place on floor for EMS to assist with transfer. EMS and the resident's emergency contact were notified. Record review of Resident #2's SNF/NF to Hospital Transfer Form, dated 10/05/2025, revealed the reason for transfer was a fall, with a most recent pain level of 10 in the left trochanter (hip) location. Resident #2 was listed as capable of making own decisions. Resident #2's usual functional status before acute change in condition was listed as ambulates independently with needs assistance for bathing, dressing, toileting, and transfers. Resident #2 was also listed as continent of bowel and bladder, and alert, oriented, and follows instructions. Resident #2 was listed as a high fall risk. Record review of facility inservices revealed the most recent inservices for: Abuse and Neglect/Resident Rights on 8/13/2025 Gait Belt Use for Safety on 4/17/2025Proof of online course completion provided for Preventing Falls: An Interdisciplinary Approach; Slips, Trips, and Falls Prevention for employees between 1/01/2025 and 10/22/2025. Interview with the Administrator on 10/21/2025 at 1:19 PM revealed the facility process when a resident was found on the ground was for a nurse to assess the resident and begin neuro checks, then to contact the medical doctor and family as soon as possible to let them know what happened. The Administrator stated ongoing monitoring of the resident would happen and if it were determined the resident needed to be sent to the hospital then the incident would be considered a significant change in condition. The Administrator revealed an unwitnessed injury, injury of unknown origin, or serious bodily injury should have been reported and investigated, however, if the facility knew the resident fell or the resident could tell them they fell then the injury was not of an unknown origin. The Administrator stated an unwitnessed fall with a fracture or serious bodily injury was not reported as the facility did not interpret an unwitnessed fall as an unknown source since they knew [the residents] fell. The Administrator stated neglect was if a resident tripped on something or some item that could have been addressed by staff, but there were no obstacles staff saw when entering the rooms of Residents #1 or #2 after they fell. When asked about the blood in the catheter bag of Resident #1, the Administrator deferred to the DON for a nursing viewpoint on how that was known to be from the unwitnessed fall. The Administrator was able to report Resident #1 was sent out to a local hospital for evaluation once blood was observed. The Administrator stated Resident #2's injury was not reported because the known source was the fall as she was found on the floor, and she was able to say that she fell and there were no reported or observed obstacles in the environment that may have caused or contributed to the fall. The Administrator stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676489 If continuation sheet Page 4 of 5 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 676489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Legacy Midtown Park 8280 Manderville Lane Dallas, TX 75231 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete she was responsible for reporting incidents of abuse. neglect, exploitation, and injuries of unknown origin, and the DON would report in her absence.Interview with CNA C on 10/21/2025 at 3:35 PM revealed unwitnessed falls were to be reported to the nurses right away, as were any changes in condition like blood being seen in the catheter bag. CNA C stated any suspicion of abuse, neglect, or exploitation, which included unexplained injuries, should be reported immediately to the abuse coordinator for the facility who was the Administrator. Interview on 10/21/2025 at 3:39 PM with LVN D revealed if a resident was found on the ground, the first step was to make sure the resident was safe and call out for help, then the resident was assessed to see if they could move extremities. LVN D stated if the resident had any pain, the doctor was to be called for orders unless it was severe then call 9-1-1 right away. LVN D stated all unwitnessed falls and injuries of unknown origin were reported to the DON and Administrator right away so they could determine if an investigation needed to happen. Interview with the DON on 10/21/2025 at 4:29 PM revealed the expectations of staff when a resident was found after an unwitnessed fall was for a CNA to call out for a nurse, the nurse to assess the resident and try to identify what caused the fall either from resident report or by looking for environmental factors. The DON stated if the resident was not expressing pain, then staff would assist to the bed and monitor for anything remarkable or for a delayed injury to be expressed. The DON stated Resident #1 was sent out to the hospital due to the blood seen in the catheter bag during follow-up checks as the follow-up checks were not remarkable for any injury because of the fall; the assessment of Resident #1 when he was found on the floor did not indicate any dislodging or trauma to the catheter. The DON stated she had limited interactions with Resident #1 during his stay at the facility and did not notice anything remarkable with his memory or ability mentally. The DON stated interactions with Resident #2 were brief and the resident was able to respond appropriately to general inquiries, however, did not have in-depth interactions with her. Resident #2 was sent to the hospital immediately due to expressing pain was severe in her hip. The DON stated the appropriate interventions were in place for both Residents #1 and #2 at the time of their unwitnessed falls. The DON stated unwitnessed falls were discussed with the Administrator and a decision was made on whether an investigation and self-reporting were necessary; the instances of Residents #1 and #2 were not required to be self-reported in their opinions.Record review of the facility's policy Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating revealed: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/ misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; e. The resident's attending physician; and f. The facility medical director. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury.; Event ID: Facility ID: 676489 If continuation sheet Page 5 of 5