Legend Oaks Healthcare And Rehabilitation - New Br

F 0641 2. Review of Resident #85's face sheet, dated 3/27/25, revealed she was admitted to the facility on [DATE REDACTED], with diagnosis including Chronic Obstructive Pulmonary with acute exacerbation. Level of Harm - Minimal harm or potential for actual harm Review of Resident 85's physician orders for March 2025 revealed an order: O2 AT 2-4L/MIN CONTINUOUS PER NC every shift active 1/31/2025 22:00. Residents Affected - Few

Review of Resident 85's annual MDS assessment, dated 2/4/25, revealed there was no indication she was receiving oxygen.

Review of Resident #85's Care Plan, revised on 2/13/25, revealed she was using oxygen related to respiratory illness.

Observation and interview on 03/26/25 at 10:59 AM revealed Resident #85 lying in bed with oxygen infusing via nasal cannula. Resident #85's family member stated he saw staff coming in periodically to check on the concentrator.

Interview on 03/27/25 at 03:56 PM with MDS Coordinator/LVN G revealed Resident #85's annual MDS did not indicate Resident #85 received oxygen. She stated it was important to accurately reflect Resident #85's status so staff would provide the necessary care and services needed.

Review of a facility policy, Resident Assessment, reviewed on 3/2023, read It is the policy of this facility to ensure that the assessment accurately reflect the resident's status.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 33 676392 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676392 B. Wing 03/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130

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 0656 Review of Resident #92's consolidated physician orders for March 2025 revealed and order for the use of 2 1/4 side rails for repositioning and mobility. Level of Harm - Minimal harm or potential for actual harm Review of Resident #92's admission MDS assessment, dated 2/23/25 revealed his BIMS score was 15 of 15 reflective of no cognitive impairment. Residents Affected - Few

Review of Resident #92's Care Plan, initiated 2/24/25, revealed no indication Resident #92 used side rails for mobility and repositioning.

Observation on 03/25/25 at 11:08 AM Resident #92 lying in bed to the left side with 1/4 side rails up on both sides of the bed.

Observation and interview on 03/25/25 at 12:25 PM revealed Resident #92 sitting in a wheelchair eating his lunch meal. He stated he was doing ok but felt cooped up. He stated life changed since his amputation and reported using the side rails for bed mobility.

Interview on 03/28/25 at 04:45 PM with MDS Coordinator/LVN G revealed the MDS would reflect the use of side rails if they met the criteria of a restraint. She further stated the use of side rails should be reflected in his Care Plan so staff would be aware that he used them. It would also ensure nursing staff monitored for any risks involved. She stated Resident #92's Care Plan did not reflect the use of side rails and it could result

in staff not monitoring the risks involved and it could further result in an accident or injury.

Review of facility policy, Comprehensive Person-Centered Care Planning, reviewed 2/2025, read 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 timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 33 676392 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676392 B. Wing 03/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130

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 0692 2. Any resident weight that varies from the previous reporting period by 5% in 30 days, 7.5% in 90 days and 10% in 180 days will be evaluated by the Interdisciplinary Team to determine the cause of weight loss/gain, Level of Harm - Minimal harm or intervention required and need for further recommendations and/or referral. Family member/responsible potential for actual harm party and attending physician will be notified.

Residents Affected - Few 3. Diets will be provided according to physician's orders, including regular and therapeutic diets. Dietician technicians and registered dieticians will make recommendations for therapeutic diets.

4. Care plan will be updated or revised as needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 33 676392 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676392 B. Wing 03/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130

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 0695 Observation on 03/27/2025 at 2:22 p.m. revealed Resident #252's oxygen concentrator had been removed from his room. Level of Harm - Minimal harm or potential for actual harm During an interview on 03/27/2025 at 3:45 p.m. the DON stated the oxygen was removed yesterday from resident's room after an assessment was performed revealing Resident #252 did not want the oxygen and Residents Affected - Some he was not hypoxic.

During an interview on 03/28/2025 5:09 p.m. the administrator stated the nurses were responsible for getting

the orders for oxygen as soon as there was change or it was needed.

Record review of facility's policy titled Oxygen Administration, revised 01/2025, read Policy: It is the policy of

this facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can be obtained.

Review of an oxygen manual which Resident #76 and Resident #85 used read in relevant part Caring for your [name] oxygen concentrator. Filter door with vents. Inspect the vents periodically and wipe with a dry cloth as needed to remove dust. Service and maintenance should only be performed by appropriately trained and authorized [name] personnel and/or service centers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 33 676392 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676392 B. Wing 03/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130

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 0700 5. Use of side rails as restraints is prohibited unless necessary to treat a resident's medical symptoms.

Level of Harm - Minimal harm or 6. Medical symptoms that warrant the use of restraints must be documented in the resident's medical record, potential for actual harm ongoing assessments, and care plans. 7. A device that does not prevent the resident from getting out of bed, or from movement, and or the resident can remove with minimal effort is not considered a restraint. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 33 676392 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676392 B. Wing 03/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130

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 the facility policy on pharmaceutical services reviewed 12/2024, under policy was It is the policy of

this facility to provide pharmaceutical services (including procedures that assure the accurate acquiring, Level of Harm - Minimal harm or receiving, dispensing, and administering of all drugs and biological) to meet the needs of each resident. And potential for actual harm under procedures was The pharmacist, in collaboration with the facility and the medical director helps develop and evaluate the implementation of pharmaceutical services procedures that address the needs of Residents Affected - Some the residents, are consistent with state and federal requirements and reflect current standards of practice.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 33 676392 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676392 B. Wing 03/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130

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 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 46677 Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were secured properly within 2 of 4 medication carts (med cart in hall 300 and med cart in hall 400) observed for medication storage.

One unidentified small round white pill was observed in the bottom drawer of the medication cart on 400 hall.

Two unidentified small round white pills were observed in the top drawer of the medication cart on 300 hall.

This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications as ordered.

The findings were:

Observation of the medication cart on 400 hall on 03/27/2025 at 2:30 PM revealed a small round white pill on

the bottom of the bottom drawer of the medication cart on 300 hall. The pill was loose and not labeled with no identifying markers to indicate what it was. Medication cart was locked and secured.

Observation of the medication cart on 300 hall on 03/27/2025 at 3:10 PM revealed two small round white pills

on the bottom of the top drawer of the medication cart on 300 hall. The pills were loose and not labeled with no identifying markers to indicate what they were. Medication cart was locked and secured.

Interview with CMA C on 03/27/2025 at 2:55 PM revealed CMA C could not identify loose pills located in medication carts for the 300 halls and 400 halls. CMA C stated if a loose pill is found in the medication carts staff are to follow the facility policy to dispose of them. CMA C stated loose pills in the medication carts could cause the resident's to go without necessary medications.

Interview with DON on 03/27/2025 at 3:41 PM revealed medications are to be stored in original packaging. DON stated CMAs check the carts daily to ensure they are clean and there are no loose pills. DON stated loose pills in the medication carts would not affect the residents since staff would now dispense loose pills.

Record review facility policy titled [Facility Name] Policy/ Procedure - Nursing Clinical section Care and Treatment subject Medication Access and Storage, E kit access, revised 07/2024, revealed 1. The provider pharmacy dispenses medications in containers that meet legal requirements, including requirements of good manufacturing practices where applicable. Medications are kept and stored in these containers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 33 676392 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676392 B. Wing 03/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130

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 During an interview on 03/27/2025 at 2:25 p.m. the dietary resource stated the divided dish by not having been dried fully and having been served with standing drops of water could cause cross contamination. The Level of Harm - Minimal harm or dietary resource further stated it could make residents very sick. The dietary resource stated the plate should potential for actual harm have been pulled once the liquid was seen and not served. The dietary resource stated she was too focused

on checking other divided plates in the kitchen and did not take the plate that was served. Residents Affected - Some

During an interview on 03/27/2025 at 2:31 p.m. the dietary supervisor stated he did not notice the water in

the divided plate when he served the grilled cheese sandwich but stated it could cause cross contamination.

The dietary supervisor further stated the dishes are air dried.

During an interview on 03/28/2025 at 4:59 p.m. the DON stated there was the potential of cross contamination of food by dishes not being dried thoroughly. The DON further stated it could have the potential for causing infections. The DON stated she felt it would be multiple people's responsibility to not serve food on improperly dried plates if it was not caught in the kitchen the other staff should catch in passing of trays.

During an interview on 03/28/2025 at 5:11 p.m. the administrator stated residents could get sick if there was cross contamination from not properly handling the dishes. The administrator further stated the dietary supervisor was responsible to ensure dishes were air dried and even the cook on duty was responsible.

Review of facility's policy Handling Clean Equipment and Utensils, not dated, read Policy: Clean equipment and utensils will be handled properly to prevent contamination. Procedure: 1. When handling cleaned and sanitized equipment, staff will avoid touching the parts that will come in contact with the food.

Review of facility's policy Cleaning Dishes/Dish Machine, not dated, read Policy: All flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use .Procedures: 9. Dishes should be air dried on the dish racks .10. Inspect for cleanliness and dryness and put dishes away if clean.

Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 2-301.14, When to Wash, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTNESILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks;.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 33 676392 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676392 B. Wing 03/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130

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 0940 O. Hazard communication (Material Safety Data Sheets, [MSDS])

Level of Harm - Minimal harm or P. Resident assessment (MOS, PASARR, PSYCH, Diags.) potential for actual harm Q. Restraints Residents Affected - Few R. ADA (American Disabilities Act)

A policy addressing required annual training including QAPI training, ethics training, behavior health training, dementia training, HIV training and fall prevention training was requested from the HR Manager on 03/28/2025 at 4:35 PM but was not provided prior to exit.

A policy addressing required annual training including QAPI training, ethics training, behavior health training, dementia training, HIV training and fall prevention training was requested from the Administrator on 03/28/2025 at 4:48 PM but was not provided prior to exit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 33 676392 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676392 B. Wing 03/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130

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 0941 D. Fire prevention and safety

Level of Harm - Minimal harm or E. Accident prevention and safety measures potential for actual harm F. Confidentiality of patient information Residents Affected - Few G. Preservation of patient dignity, including provision for privacy

H. Patient rights and civil rights

I. HIPAA

J. Signs and symptoms of cardiopulmonary distress

K. Choking prevention and intervention

L. Sexual Harassment

M. Elder Abuse and residents rights

N. Blood borne pathogens (HIV, Hepatitis B)

O. Hazard communication (Material Safety Data Sheets, [MSDS])

P. Resident assessment (MOS, PASARR, PSYCH, Diags.)

Q. Restraints

R. ADA (American Disabilities Act)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 33 676392 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676392 B. Wing 03/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130

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 0943 Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Level of Harm - Minimal harm or potential for actual harm 46677

Residents Affected - Few Based on interview and record review, the facility failed to provide mandatory training on Dementia management training for 1 (Cook D) of 28 employees reviewed for training.

The facility failed to ensure Dementia management training was provided to [NAME] D annually.

This failure could place residents at risk of being uninformed due to lack of staff training.

The findings include:

Record review of the personnel records for [NAME] D revealed a hire date of 12/16/2023. Further review of a training log for [NAME] D from the previous 15 months, provided by the HR Manager revealed no evidence of dementia training being provided annually prior to March 25, 2025. The training log for [NAME] D revealed annual dementia trainings was last completed on 01/26/2024.

Interview with the HR Manager on 03/28/2025 at 4:35 PM revealed the facility relied on the training program Relias to identify staff who had annual trainings due within 30 days. The HR Manager stated he ran a weekly report in Relias to identify employees who needed to complete annual trainings. The HR Manager stated [NAME] D did not show up on any reports of the weekly reports. The HR manager stated it was his responsibility to run the weekly reports and to provide them to the department heads who were responsible to ensure their staff completed trainings. The HR Manager stated by not training staff annually it increased

the likelihood a staff member could do something wrong and put the residents in harm's way.

Interview with the Administrator on 03/28/2025 at 4:48 PM revealed HR and Administrator were to ensure staff received their annual trainings. The Administrator stated a report was run in Relias to identify staff who had trainings that were due in the next 30 days, and it was the responsibility of the department heads to ensure staff completed trainings. The Administrator stated staff were required to complete trainings to ensure

they were up to date on policies and procedures to ensure quality care was being provided. The Administrator stated if staff were not trained it put residents at risk for receiving poor care.

A policy addressing required annual training including dementia training was requested from the HR Manager on 03/28/2025 at 4:35 PM but was not provided prior to exit.

A policy addressing required annual training including dementia training was requested from the Administrator on 03/28/2025 at 4:48 PM but was not provided prior to exit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 33 676392 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676392 B. Wing 03/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130

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 0944 Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Level of Harm - Minimal harm or potential for actual harm 46677

Residents Affected - Few Based on interview and record review the facility failed to include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of it's QAPI program for 1 (Cook D) of 28 employees reviewed for training requirements.

The facility failed to ensure required QAPI trainings was provided to [NAME] D annually.

This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Findings include:

Record review of the personnel records for [NAME] D revealed a hire date of 12/16/2023. Further review of a training log for [NAME] D from the previous 15 months, provided by the HR Manager revealed no evidence of QAPI training being provided annually prior to March 25, 2025. The training log for [NAME] D revealed annual QAPI training was last completed on 01/26/2024.

Interview with the HR Manager on 03/28/2025 at 4:35 PM revealed the facility relied on the training program Relias to identify staff who had annual trainings due within 30 days. The HR Manager stated he ran a weekly report in Relias to identify employees who needed to complete annual trainings. The HR Manager stated [NAME] D did not show up on any reports of the weekly reports. The HR manager stated it was his responsibility to run the weekly reports and to provide them to the department heads who are responsible to ensure their staff completed trainings. The HR Manager stated by not training staff annually it increased the likelihood that a staff member could do something wrong and put the residents in harm's way.

Interview with the Administrator on 03/28/2025 at 4:48 PM revealed HR and the Administrator were to ensure staff received their annual trainings. The Administrator stated a report was run in Relias to identify staff who had trainings that were due in the next 30 days, and it was the responsibility of department heads to ensure staff completed trainings. The Administrator stated staff were required to complete trainings to ensure they were up to date on policies and procedures to ensure quality care was being provided. The Administrator stated if staff were not trained it put residents at risk for receiving poor care.

A policy addressing required annual training including QAPI training was requested from the HR Manager on 03/28/2025 at 4:35 PM but was not provided prior to exit.

A policy addressing required annual training including QAPI training was requested from the Administrator on 03/28/2025 at 4:48 PM but was not provided prior to exit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 33 676392 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676392 B. Wing 03/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130

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 0945 Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Level of Harm - Minimal harm or potential for actual harm 46677

Residents Affected - Few Based on interview and record review, the facility failed to include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program for 1 (Cook D) of 28 employees reviewed for training.

The facility failed to ensure standards, policies, and procedures for an infection prevention and control program training was provided [NAME] D annually.

This failure could place residents at risk of being uninformed due to lack of staff training.

The findings include:

Record review of the personnel records for [NAME] D revealed a hire date of 12/16/2023. Further review of a training log for [NAME] D from the previous 15 months, provided by the HR Manager revealed no evidence of infection control training being provided annually prior to March 25, 2025. The training log for [NAME] D revealed annual infection control trainings was last completed on 01/26/2024.

Interview with the HR Manager on 03/28/2025 at 4:35 PM revealed the facility relied on the training program Relias to identify staff who have annual trainings due within 30 days. The HR Manager stated he ran a weekly report in Relias to identify employees who needed to complete annual trainings. The HR Manager stated [NAME] D did not show up on any reports of the weekly reports. The HR manager stated it was his responsibility to run the weekly reports and to provide them to the department heads who are responsible to ensure their staff complete trainings. The HR Manager stated by not training staff annually it increased the likelihood that a staff member could do something wrong and put the residents in harm's way.

Interview with the Administrator on 03/28/2025 at 4:48 PM revealed HR and the Administrator were to ensure staff received their annual trainings. The Administrator stated a report was run in Relias to identify staff who had trainings that were due in the next 30 days, and it was the responsibility of the department heads to ensure staff completed trainings. The Administrator stated staff were required to complete trainings to ensure

they were up to date on policies and procedures to ensure quality care was being provided. The Administrator stated if staff were not trained it put resident at risk for receiving poor care.

Record review of facility policy titled In Service Training Program, dated April 2004, revealed 8. The following in-service training classes are mandatory (i.e., each employee must attend a training class on each of the following topics):

A. Problems and needs of the aged chronically ill, acutely ill, and disabled patients

B. Prevention and control of infections

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 33 676392 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676392 B. Wing 03/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130

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 0946 Provide training in compliance and ethics.

Level of Harm - Minimal harm or 46677 potential for actual harm Based on interview and record review, the facility failed to provide mandatory ethics training for 1 (Cook D) of Residents Affected - Few 28 employees reviewed for training.

The facility failed to ensure ethics training was provided to [NAME] D annually.

This failure could place residents at risk of being uninformed due to lack of staff training.

The findings include:

Record review of the personnel records for [NAME] D revealed a hire date of 12/16/2023. Further review of a training log for [NAME] D from the previous 15 months, provided by the HR Manager revealed no evidence of ethics training being provided annually prior to March 25, 2025. The training log for [NAME] D revealed annual ethics trainings was last completed on 01/25/2024.

Interview with the HR Manager on 03/28/2025 at 4:35 PM revealed the facility relied on the training program Relias to identify staff who had annual trainings due within 30 days. The HR Manager stated he ran a weekly report in Relias to identify employees who needed to complete annual trainings. The HR Manager stated [NAME] D did not show up on any reports of the weekly reports. The HR manager stated it was his responsibility to run the weekly reports and to provide them to the department heads who were responsible to ensure their staff completed trainings. The HR Manager stated by not training staff annually it increased

the likelihood that a staff member could do something wrong and put the residents in harm's way.

Interview with the Administrator on 03/28/2025 at 4:48 PM revealed HR and the Administrator were to ensure staff received their annual trainings. The Administrator stated a report was run in Relias to identify staff who had trainings that were due in the next 30 days, and it was the responsibility of department heads to ensure staff completed trainings. The Administrator stated staff were required to complete trainings to ensure they were up to date on policies and procedures to ensure quality care was being provided. The Administrator stated if staff were not trained it put resident at risk for receiving poor care.

A policy addressing required annual training including ethics training was requested from the HR Manager on 03/28/2025 at 4:35 PM but was not provided prior to exit.

A policy addressing required annual training including ethics training was requested from the Administrator

on 03/28/2025 at 4:48 PM but was not provided prior to exit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 33 676392 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676392 B. Wing 03/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130

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 0949 Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Level of Harm - Minimal harm or 46677 potential for actual harm Based on interview and record review, the facility failed to provide behavioral health training consistent with Residents Affected - Few the requirements at S483.40 and as determined by the facility assessment at S483.71 for 1 (Cook D) of 28 employees reviewed for training.

The facility failed to ensure behavioral health training was provided to [NAME] D annually.

This failure could place residents at risk of being uninformed due to lack of staff training.

The findings include:

Record review of the personnel records for [NAME] D revealed a hire date of 12/16/2023. Further review of a training log for [NAME] D from the previous 15 months, provided by the HR Manager revealed no evidence of behavior health training being provided annually prior to March 25, 2025. The training log for [NAME] D revealed annual behavior health training was last completed 01/26/2024.

Interview with the HR Manager on 03/28/2025 at 4:35 PM revealed the facility relied on the training program Relias to identify staff who had annual trainings due within 30 days. The HR Manager stated he ran a weekly report in Relias to identify employees who needed to complete annual trainings. The HR Manager stated [NAME] D did not show up on any reports of the weekly reports. The HR manager stated it was his responsibility to run the weekly reports and to provide them to the department heads who were responsible to ensure their staff completed trainings. The HR Manager stated by not training staff annually it increased

the likelihood a staff member could do something wrong and put the residents in harm's way.

Interview with the Administrator on 03/28/2025 at 4:48 PM revealed HR and the Administrator were to ensure staff received their annual trainings. The Administrator stated a report was run in Relias to identify staff who had trainings that were due in the next 30 days, and it was the responsibility of the department heads to ensure staff completed trainings. The Administrator stated staff were required to complete trainings to ensure

they were up to date on policies and procedures to ensure quality care was being provided. The Administrator stated if staff were not trained it put resident at risk for receiving poor care.

A policy addressing required annual training including behavior health training was requested from the HR Manager on 03/28/2025 at 4:35 PM but was not provided prior to exit.

A policy addressing required annual training including behavior health training was requested from the Administrator on 03/28/2025 at 4:48 PM but was not provided prior to exit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 33 676392