Legend Oaks Healthcare And Rehabilitation Center -

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

went off and she immediately brought the resident back in. In an interview on 11/12/25 at 10:55 AM, the DON said in April 2025 Resident #1 was visualized going out the door at the end of the hall by ADON A but

the staff could not get to her before she went out the door. She send ADON A was alerted to Resident #1 going out the door by an audible alarm, and then immediately returned the resident inside the facility. The DON said Resident #1 was in a wheelchair and she propelled herself around the building, was combative and resistant to care. She said the MDS represented the resident and the care they should receive. The DON said an inaccurate MDS could potentially impact how the resident is cared for. In an interview on 11/12/25 at 11:30 AM, the MDS Nurse said she was new and did not complete Resident #1's assessments.

She said the MDS is completed with information from the IDT as well as interviews and observations with family and the resident. She said from what she heard, Resident #1 had behaviors of resisting care but her MDS was codded as no behaviors. The DON said Resident #1 had behaviors since she admitted to the facility in 2024. She said the resident was not friendly, had behaviors most of the time, would grab staff, had verbal behavioral symptoms, roamed in her wheelchair, wandered around and rejected care 4-6 times a week. After the DON reviewed Resident #1's MDS from 10/03/25 and 10/28/25 she said they were inaccurate because they did not acknowledge Resident #1's physical, verbal and other behavioral symptoms. An observation on 11/12/25 at 11:54 AM revealed, Resident #1 sitting in her wheelchair in the doorway of her room receiving Vancomycin 750 mg/ml in 750 ml IV at 250 ml/hr. Her left foot was wrapped

in a white dressing and her right arm had IV tubing protruding from under a white gauze dressing. The IV bag had no labeling outside of the manufacturer labeling, there was no pharmacy label that contained the resident's name, dose and instruction for use, administration flow rate, name of prescriber, or date the medication was ordered. Observation revealed a dial a flow pump. The resident was not interviewable, she was confused, tugged on her IV tubing and was combative with staff who passed by. In an interview on 11/12/25 at 11:58 AM, RN A said Resident #1 was confused and was not interviewable. She said the resident was combative and resistant to care, she would not let anyone touch her or provide care. Record

review of the facility policy titled Resident Assessment and Associated Processes revised 04/2025 revealed, It is the policy of this facility that resident will be assessed and the findings documented in their clinical health record. These will be comprehensive, accurate, standardized reproducible assessment of each resident and will be conducted initially and periodically as part of an ongoing process through which each resident's preferences and goals of care, functional and health status, and strengths and needs will be identified. An accurate Comprehensive Assessment will be made of the resident's needs, strengths, goals, life history and preferences, using the RAI (Resident Assessment Instrument) and will include at least the following: Identification and demographic information; Customary routine; Cognitive patterns; Communication, Vision; Mood and behavior patterns; Psychological well-being. 5. Assessment information will be used to develop, review, and revise the resident's comprehensive care plan. 7. Each individual who completes a portion of the assessment will electronically sign and certify the accuracy of that portion of the assessment, as well as the date the data was obtained.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Legend Oaks Healthcare and Rehabilitation Center -

8902 West Rd Houston, TX 77064

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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

risk of infusion reactions, administer Vancomycin Injection over a period of 60 minutes or greater and also prior to intravenous anesthetic agent. ADVERSE REACTIONS: The common adverse reactions are anaphylaxis, red man syndrome, acute kidney injury, hearing loss, neutropenia (low type of white blood cell). Record review of the facility policy Administering Medications revised 05/18/2023 revealed, Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. 3. Medications must be administered

in accordance with the orders, including any required time frame. 6. The individual administering the medication must check the label to verify the right medication, right dosage, right time and right method (route) of administration before giving the medication. 20. New personnel authorized to administer medications will not be permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Legend Oaks Healthcare and Rehabilitation Center -

8902 West Rd Houston, TX 77064

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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

administration; 2. Right Time - Medications are administered within prescribed time frames. 3. Right Medication - Medications are checked against the order before they are given. 4. Right Dose - Medications are administered according to the dose prescribed Record review of the manufacturer's Highlights of Prescribing Information revised 05/2021 revealed, Infusion Reactions: Hypotension, including shock and cardiac arrest, wheezing, dyspnea (shortness of breath), urticaria (hives), muscular and chest pain and red man syndrome which manifests as pruritus (itching) and erythema (redness) that involves the face, neck and upper torso may occur with rapid intravenous administration. To reduce the risk of infusion reactions, administer Vancomycin Injection over a period of 60 minutes or greater and also prior to intravenous anesthetic agent. ADVERSE REACTIONS: The common adverse reactions are anaphylaxis, red man syndrome, acute kidney injury, hearing loss, neutropenia (low type of white blood cell). Record review of the facility policy Administering Medications revised 05/18/2023 revealed, Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation:

1. 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer

medications and/or have related functions. 3. Medications must be administered in accordance with the orders, including any required time frame. 6. The individual administering the medication must check the label to verify the right medication, right dosage, right time and right method (route) of administration before giving the medication. 20. New personnel authorized to administer medications will not be permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility. Record review of the facility policy titled Nursing Staff Competency revised 04/2025 revealed, Policy: It is the policy of this facility to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required.

Procedure: 2. Within 30 days of the date of hire, the nursing staff member shall complete the orientation competency assessment for the appropriate job category to meet the needs of the facility's resident population in accordance with the facility assessment. a. Competency in skills and techniques to care for residents' needs may include but are not limited to: Medication management

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Legend Oaks Healthcare and Rehabilitation Center -

8902 West Rd Houston, TX 77064

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 0732

Post nurse staffing information every day.

Level of Harm - Potential for minimal harm

Based on observation, interview, and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 1 of 1 facility reviewed for required postings. - On 11/12/25 the facility failed to ensure the Direct Care Daily Staffing Numbers were updated. The postings read 11/11/25.

This failure could affect residents, facility visitors, vendors, and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings Included: An observation on 11/12/25 at 08:51 AM revealed, the facility Direct Care Daily Staffing Numbers displayed on the pony wall on the left side of the front entrance. The posting read Date: 11-Nov-2025' and included the facility name, census, the scheduled hours, and staffing totals for direct care staff. RNs, LVNs and some CNAs worked 12 hour shifts from 6:00 AM to 6:00 PM or 6:00 PM to 6:00 AM. Nursing Managers and the DON worked from 9:00 AM to 5:00 PM, CNAs: 10:00 PM to 6:00 AM, CMAs 6:00 AM - 2:00 PM and 2:00 PM to 10:00 PM. An observation on 11/12/25 at 08:51 AM revealed, the facility Direct Care Daily Staffing Numbers displayed on the wall by the DON's office. The posting read Date: 11-Nov-2025' and included the facility name, census, the scheduled hours, and staffing totals for direct care staff. RNs, LVNs and some CNAs worked 12 hour shifts from 6:00 AM to 6:00 PM or 6:00 PM to 6:00 AM. Nursing Managers and the DON worked from 9:00 AM to 5:00 PM, CNAs: 10:00 PM to 6:00 AM, CMAs 6:00 AM - 2:00 PM and 2:00 PM to 10:00 PM. An observation on 11/12/25 at 09:08 AM revealed, the Staffing Coordinator as

she removed the old direct care posting from the wall by the DONs office. In an interview on 11/12/25 at 10:38 AM, the Administrator said the Staffing Coordinator was responsible for the direct care posting. He said the posting should be posted somewhere visible within 2 hours of the first shift. He said the facility had 12 hour shifts for nurse and CNAs from 6- 6 and the posting should be up by 8:00 AM and before each shift. The Administrator said failure to update the posting timely could cause family members confusion of who was giving care that day. In an interview on 11/12/25 at 11:16 AM, the Staffing Coordinator said she made the schedules for the nursing department, found staffing, worked as a CNA/MA as needed and she was responsible for the daily direct care posting. She said the direct care posting had to be posted within 2 hours of the shifts, the facility shifts were 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM and must include

the facility name, date, census, staffing types scheduled and the total number of scheduled staff. She said failure to update the posting timely could result in residents and visitors to the building not knowing the facility census or the staffing available for the day. The Staffing Coordinator said her shifts typically ran from 08:15 AM to 05:15 PM and she was expected to update the posting within 2 hours of the beginning of her shift. She said she had not received any training about the regulations regarding the timing of the posting.

The Staffing Coordinator said when she arrived on 11/12/25 she was helping residents on the floor which caused her update of the posting to be delayed.

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Legend Oaks Healthcare and Rehabilitation Center -

8902 West Rd Houston, TX 77064

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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

and/or have related functions. 3. Medications must be administered in accordance with the orders, including any required time frame. 6. The individual administering the medication must check the label to verify the right medication, right dosage, right time and right method (route) of administration before giving the medication. 20. New personnel authorized to administer medications will not be permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Legend Oaks Healthcare and Rehabilitation Center -

8902 West Rd Houston, TX 77064

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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

have a pharmacy label that included the pharmacy's information, resident's name, medication information and directions for use. A bag of Resident #1's IV Vancomycin was observed in the fridge with each IV bag wrapped in a foil manufacturer bag and an attached pharmacy label with pharmacy information, resident information, provider information, drug information and directions for use. The label read Vancomycin 750 ml: Infuse intravenously 150 ml (750 mg) over 60 minutes every 12 hours for 10 days. The DON said failure to label medication could result in staff being unaware of the instructions for use including the dosing.

Record review of the facility policy titled Infusion Therapy Product Labels revised 11/13/2018 revealed, Policy: Infusion therapy products are labeled in accordance with facility requirements and applicable state and federal laws. The label includes sufficient additional information as required to assure safe and efficient administration to residents. Procedures: a. Infusion therapy products are labeled by the provider with: 1) Resident name; 2) Physician name; 3) Pharmacy name, address, and telephone number 4) Contents of solution, including: a) Name of diluent (e.g., NS); b) Name and amounts of each additive; 5) Date dispensed 6) Directions for administration ; 7) Prescription number; 8) Storage instructions; 9) Expiration date and time; 10) Initials of dispensing pharmacist.

Event ID:

Facility ID:

If continuation sheet