Health inspection·December 7, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ankle). Resident #1 did not have any bruises, red marks, or scratches on her body. Signed by Wound Care Nurse Record review of a note in the investigation file for Resident #1, dated 10/18/2023, revealed Social Worker interviewed Resident #1 after the alleged physical abuse. Social Worker asked Resident #1 if she felt safe in the facility and Resident #1 stated yes. She also asked Resident #1 did any nurse aide hit her or harmed her and Resident #1 stated no. The Director of Nurses entered the room and assisted with Resident #1's follow-up interview. Resident #1 knew CNA A (allegedly slapped Resident #1) and Resident #1 stated she loved her and was not scared of her. Reviewed safety checks on interviewable residents on 100 hall and all felt safe and stated CNA A (allegedly abused Resident #1) was good to them and they all loved her. All residents interviewed stated they felt safe at the facility and having CNA A giving them care. Record review of CNA B statement in the investigation file, dated 10/18/2023, revealed approximately 10:15 AM she witnessed a co-worker CNA A hit Resident #1 in the face on each side of Resident #1's face. She stated Resident #1-bit CNA A on the arm. CNA B also wrote in her statement she reported the incident at 11:15 AM to Human Resource Coordinator after checking if the Administrator was in the facility. Record review of the Director of Nurses interview in the investigation file with CNA A, dated 10/18/2023, revealed CNA A stated she was giving ADL care to Resident #1 approximately 10:45 AM on 10/18/2023. CNA A stated Resident #1 became upset when she was attempting to pull up Resident #1's pants. CNA A stated this is when Resident #1 bit her on the arm. CNA A stated CNA B was on the opposite side of the privacy curtain, assisting ADL care with Resident #1's roommate. CNA A stated she asked Resident #1 why she bit her that it hurt. Director of Nurses documented she interviewed Resident #1, and she loved the CNAs and she felt safe. Record review of weekly skin assessments after 10/18/2023 reflected no bruises, scratches, red marks on Resident #1. Record review of nurse's notes dated, 10/18/2023, at 12:32 PM reflected Resident #1 had a head-to-toe assessment completed with the following findings: Bilateral heels noted to be clear, dry and intact with no signs of skin breakdown. Sacrum, Coccyx, and bilateral buttocks noted to be clear, dry, and intact with no signs or symptoms of skin breakdown. Left lower leg noted with old, scabbed area from prior wounds. No skin breakdown under bilateral breast. No skin tears present. No bruising noted. All other pressure areas including bilateral malleoulus (a bony projection on the ankle), knees, hips, shoulders, and back of head are clear, dry, and intact with no signs of skin breakdown. This was the only nurse's documentation on 10/18/2023. Record review of nurse's notes dated, 10/19/2023, revealed Resident #1 did not have any signs/ or symptoms of distress. There was not any documentation of resident having any type of change in mood or behavior such as: anxiety, depression, and/or being afraid. Observation on 12/07/2023 at 9:15 AM reflected information on Abuse Coordinator name/ phone number was posted in common area where staff and residents were able to see this information. Observation on 12/07/2023 at 9:30 AM reflected prior to entering Resident #1's room, there was a CNA (did not know the name of the CNA at the time of the observation) in Resident #1's room assisting Resident #1 put on a sweater. The CNA did not realize anyone was near the door observing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 2 of 8 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 455351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy Nursing and Rehabilitation 2817 Kent Street Bryan, TX 77802 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 staff/resident interaction. Resident #1 was smiling and talking with the CNA. Resident #1 stated to the CNA I like you to help me you are so good to me. The CNA stated, you are like an auntie to me. The CNA exited from the privacy curtain and spoke upon exiting the room. In an interview on 12/07/2023 at 9:40 AM Resident #1 stated did you see that girl leave here. She stated I want to tell you something she (CNA A) was good to me and everyone. She stated I did bite her one time, but I did not want her to put my clothes on me, and she was just helping me. I do not know why I bit her, but I sure did. Resident #1 stated that girl (CNA A) smiled at me and said don't bite people it hurts. Resident #1 stated no one had ever slapped or hit her. She stated she would scream so loud if anyone did hit her. She stated all the staff was nice to her. In an interview on 12/07/2023 at 10:00 AM CNA C stated she usually worked on 100 hall with CNA A and very few times with CNA B. She stated she had never witnessed CNA A verbally or physically abusing any resident. She stated the residents frequently wants CNA A to give them care more than anyone else. CNA C stated CNA B did not like CNA A and she was always making sarcastic remarks to CNA A. She stated Resident #1 loved CNA A and usually Resident #1 was more cooperative with care when CNA A gave her care. CNA C stated Resident #1 will hit different staff depending on her mood at the time and usually if the staff waits a few minutes and return to Resident #1's room with CNA A Resident #1 was more cooperative. She stated she had not heard any residents ever complain about CNA A. She stated she had been in serviced on abuse and neglect. She stated abuse was when someone told a resident they were stupid, cussed a resident, and /or hit a resident. She stated neglect when staff refuse to change a resident when the resident would be soiled, refuse to feed a resident or refuse to give medication to a resident. She also stated CNA B tried to cause drama with all the staff and tried to instigate issues and it was peaceful since CNA B was no longer an employee at the facility. CNA C also stated the Administrator was the abuse coordinator. She stated if she witnessed someone abusing a resident, she was to ask the staff to leave the area where the resident was and to immediately notify the abuse coordinator and if he was not available to either call him or report to the Director of Nurses. Observation/Interview on 12/07/2023 at 10:14 AM there was a CNA in room [ROOM NUMBER] A and the resident in A bed was laughing and talking to the CNA (did not know the name of the CNA at time of observation). The resident and CNA were laughing very loud. The resident in 108 A stated, I am so happy you are here you make everyone happy. When entered the room the CNA and resident was holding hands and laughing at something on television. Resident introduced herself as Resident #2 and the CNA introduced herself as CNA A. CNA explained she needed to go check on another resident and she would see Resident #2 later. Resident #2 stated come back and see me I will need you to help me after lunch and CNA A agreed. Interviewed Resident #2 and she stated CNA A was so kind to everyone and would laugh with all the residents. She stated she is the best CNA we have in this place. Resident #2 stated she was not afraid to live here and loved the attention she received from the people that worked in the building. In an interview on 12/07/2023 at 10:49 AM CNA A stated approximately 10:45 AM on 10/18/2023 she stated she was in Resident #1's room giving ADL care. She stated CNA B was giving ADL care to Resident #1's roommate. She stated the curtain was pulled for privacy and she could not see what CNA B was doing and with the privacy curtain pulled it would be very difficult for CNA B to see anything she was doing with Resident #1. CNA A stated Resident #1 can become a little agitated during ADL care. She stated when she would refer to Resident #1 as Auntie, she would be more cooperative with care most of the time. CNA A stated she dressed Resident #1 (she is a one person assist) and assisted her to the edge of the bed to transfer Resident #1 to her wheelchair. She stated during the transfer of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 3 of 8 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 455351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy Nursing and Rehabilitation 2817 Kent Street Bryan, TX 77802 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 Resident #1 from the bed to the wheelchair Resident #1 bit her on her left upper arm. She stated she asked Resident #1 why she bit her, and Resident #1 denied biting CNA A. She stated CNA B was on the other side of privacy curtain and she informed CNA B that Resident #1 bit her. CNA A stated CNA B did not witness Resident #1 biting her. She stated CNA B made a sarcastic remark to her and exited the room. She stated CNA B was constantly making sarcastic remarks to her and she was surprised CNA B spoke to her. She stated CNA B did not ever speak to her in the facility except to make sarcastic remarks. CNA A stated Resident #1 was calm and was not agitated when she dressed her and transferred her from bed to the wheelchair. CNA A stated this was one time Resident #1was not agitated during care, and she was surprised when Resident #1 bit her. CNA A also stated when she exited the room, she went to the wound care nurse and asked if he would put some ointment on her arm. She stated the wound care nurse asked her what happened, and she stated she explained Resident #1 bit her during transfer. CNA A stated she continued giving care to the residents and completing her tasks for the day. She stated Director of Nurses came to her and asked her to come to her office. She stated thought it was about Resident #1 biting her reason she was being called to the Director of Nurses office. CNA A also stated the Director of Nurses stated there was an abuse allegation against her concerning slapping Resident #1. CNA A stated she explained to the Director of Nurses exactly what she stated in this interview. She stated she was shocked and never been through any type of abuse allegation before and did not know what to expect. CNA A stated the Director of Nurses explained she would be suspended until investigation was completed. CNA A stated she was off on 10/19/2023 and she received a phone call from the Staffing Coordinator on 10/19/2023 and was explained the facility did not find any evidence she abused Resident #1 and she was allowed to come back to work on 10/20/2023. CNA A also stated she had always worked 100 hall and she was assigned to 100 hall on 10/20/2023. She stated she had been in serviced on abuse and neglect. She stated abuse is when someone hits a residents, cusses a resident and/or could be sexual abuse. She stated neglect was when staff refuse to assist a resident to the bathroom or refuse to give resident any water. She stated the Administrator was the Abuse Coordinator and all abuse required to be reported to him and if he was not available, she stated she would report it to Director of Nurses. In an interview on 12/07/2023 at 11:58 PM Unit Manager LPN D stated she has worked with CNA A several times and she had not witnessed CNA A physically or verbally abuse any residents. She stated if any residents had a concern about staff, she would be made aware of the concern. She stated no resident had voiced a concern about any staff being physically abusive to them. Unit Manager LPN D stated the Administrator was the abuse coordinator and anytime abuse is suspected the staff was to report the abuse immediately to the Administrator. She also stated she had been in serviced on abuse and neglect. She stated abuse is when someone kicks a resident, yells at a resident, or cusses a resident. She stated neglect was when staff knowingly not giving resident their meal, medications and/ or water. In an interview on 12/07/2023 at 12:10 PM LPN E stated he frequently worked on 100 hall. He stated he had worked with CNA A numerous times. He stated all the residents on 100 hall loved CNA A. He stated he had not witnessed any residents express any concerns about CNA A. LPN E stated the families and residents all want CNA A as their CNA when she is working. He stated he had also worked with CNA B several times and she is not as friendly and tries to cause problems between the staff including CNA A. He stated he had received Inservice on abuse and neglect in October. He stated the Abuse Coordinator name and phone number was on the wall for everyone in the facility to know the information. In an interview on 12/07/2023 at 12:22 PM Wound Care Nurse stated he did put ointment on the area on CNA Right arm. He stated CNA explained to him Resident #1 bit her. He stated if any Residents had any type of skin concern such as a bruise, skin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 4 of 8 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 455351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy Nursing and Rehabilitation 2817 Kent Street Bryan, TX 77802 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 tear, wound, and/or pressure ulcer he would be notified. He stated he oversees documenting on all skin concerns in the facility. The wound care nurse stated Resident #1 to his knowledge never had a bruise, new wound or skin tear. He stated if she had red marks anywhere on her body it would be reported to him. Wound Care Nurse stated on 10/18/2023 he did complete a head-to-toe assessment on Resident #1 approximately 11:30 and there were no concerns of her skin except an old scab on her left shin. He stated there was not any evidence she had been slapped on her face such as red area, handprint, or skin begin to bruise. He also stated when he did the head-to-toe skin assessment Resident #1 was calm and in a good mood. He stated he received Inservice on abuse and neglect in October but did not recall the date. She also stated the staff was happier since CNA B was no longer an employee at the facility. He also stated the Administrator was the abuse coordinator and if he witnessed any type of abuse or neglect to report it to the administrator and if he was not in the building to report it to the Director of Nurses. He stated anyone can call the Administrator at any time and report abuse. He also stated abuse was when someone pinched a resident, yelled at a resident, and/or hit a resident. He stated neglect was when a staff refused to give resident pain medicine at scheduled time, refused to give resident a shower or change the resident brief when soiled. He stated he had been in serviced on abuse and neglect in October 2023. In an interview on 12/07/2023 at 12:40 PM Director of Nurses stated Human Resource Coordinator came to her office approximately 11:30 AM on 10/18/2023 and informed me that CNA B came to her and reported possible abuse to Resident #1 by CNA A. She stated she immediately asked CNA A to come to her office. CNA A stated she was giving care to Resident #1 and the privacy curtain was pulled and CNA B was on the other side of the privacy curtain. She stated CNA explained when she transferred Resident #1 this was when Resident #1-bit CNA A. She stated she did take a picture of the area on CNA A's right arm. She stated CNA denied hitting Resident #1. The Director of Nurses stated she explained to CNA A they would need to suspend her until the facility had a chance to investigate the allegation. She stated CNA A was escorted out of the facility. She also stated she immediately told the wound care nurse to complete a head-to-toe skin assessment on Resident #1 and she informed the Social Worker to interview Resident #1 and to complete safe assessment checks on the residents resides on 100 hall. The Director of Nurses stated she informed the Administrator of the allegation of abuse on Resident #1 approximately 15 minutes of her being notified at 11:30 AM. She also stated after she interviewed CNA A, she interviewed CNA B. She stated CNA B was laughing and smiling throughout the interview. She stated CNA B stated she was giving care to Resident #3 and the privacy curtain was closed. CNA B stated she heard CNA A state to Resident #1 you bit me. CNA B stated CNA A began to slap Resident #1 with one hand and then used the other hand and was constantly slapping her for several minutes. The Director of Nurses stated what CNA B stated in the interview was not what she documented on paper. She stated she went immediately and observed Resident #1. She stated Resident #1 was calm. There were no signs of redness on her face or any type of injury such as a skin tear, bruising or hand marks on her face. She stated Resident #1 was not in distress and was calm and talking. Resident #1 denied anyone hitting her. The Director of Nurses stated Resident #1 mood, behaviors, physical condition did not make any changes after the alleged abuse on 10/18/2023. In an interview on 12/07/2023 at 1:30 PM CNA F stated she had worked with CNA A before and she had never witnessed CNA A abusing a resident. She stated CNA A was always laughing with the residents and the residents loved her to be their CNA. She stated if she had witnessed anyone abusing a resident, she would report it to the Administrator who was the abuse coordinator. She stated if the Administrator was not available, she would report it to the Director of Nurses. She stated she did not like working with CNA B because she would try to cause issues between the staff, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 5 of 8 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 455351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy Nursing and Rehabilitation 2817 Kent Street Bryan, TX 77802 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 it was stressful working with her. She stated it has been less stress since CNA B no longer works at the facility. She stated CNA B would make sarcastic remarks to staff as she passed them in the hall. CNA F stated she had been in serviced on abuse and neglect. She stated abuse was when staff hit a resident, called the residents names such as idiot or dumb, and/or could be sexual abuse. She stated neglect was when staff refused to give a resident a bath, feed a resident and/ or refuse to assist a resident to the bathroom. In an interview on 12/07/2023 at 1:45 PM Resident # 3 she did not respond to any questions. She kept falling asleep. In an interview on 12/07/2023 at 2:15 PM CNA G stated she was terminated and wanted the Administrator, Director of Nurses, Staff Coordinator and all the Unit Managers fired. She stated CNA B informed her of the allegation of CNA A slapping Resident #1. She stated she informed CNA B she needed to report it to administration. She stated she was not concerned about the allegation of the abuse. She stated she did not know if the allegation was true. CNA G stated she was friends with CNA B, and she tried to distance herself from CNA B at the facility. She stated CNA B was trying to deliberately cause problems between the CNAs. She stated she had worked with CNA A, and she did not like CNA A because her friend CNA B did not like her and was trying to get her into trouble by accusing CNA A of stealing her food. CNA G stated she was CNA B's only friend she had at the facility because no one liked CNA B. She stated if she was going to be truthful, she did not believe CNA A abused anyone. She stated all the residents liked CNA A and wanted CNA A to give them care instead of CNA B. She stated CNA A was always laughing with the residents and that the residents loved for her to laugh with them. CNA G stated she did not have any worries of CNA A giving care to the residents. She stated what her concern was she was terminated, and she wanted all the administration fired. In an interview on 12/07/2023 at 2:35 PM, CNA B stated she was the one that made the accusation against CNA A. CNA B stated she was not at the facility, and she was terminated. She stated she was in Resident #1's room giving care to Resident #3. She stated the privacy curtain was not pulled between them and she could see everything occurring with Resident #1. CNA B stated Resident #1 was sitting on the bed and watching CNA A and this is when CNA slapped Resident #1 one time across the face. CNA B stated she did not know why CNA A slapped Resident #1. After asking CNA B to describe what occurred she stated it happened so fast. She stated CNA A slapped her one time across the face. CNA B stated she did not prefer to be around CNA A, and they did not speak very often. When asked CNA B to describe again what occurred when CNA A allegedly slapped Resident #1, she stated CNA A slapped her 10 times across the face and one time she hit her on the face with her fist and her there was a mark on her face that was bleeding. She stated the wound care nurse came in and saw where there was a huge scratch on Resident #1's face and blood coming for the scratch. CNA B also stated CNA A was cussing and yelling at Resident #1 when Resident #1 bit her. She stated she saw Resident #1 bite CNA A and CNA A began hitting Resident #1 across the face again. CNA B stated she did not know why she stated CNA A slapped Resident #1 ten times across the face that was not accurate. She stated CNA A slapped Resident #1 five times across the face with both hands. CNA B stated she was in serviced on abuse and neglect. She stated when she witnessed anyone abusing a resident, she was expected to assist the staff out of the room and immediately go to the Administrator who was the abuse coordinator and if he was not in the facility to go to the Director of Nurses. She stated reason she went to the human resource person was she did not want CNA A to know she reported her for abuse. She stated she walked out of the room and did not go and report the abuse immediately. She later stated in the interview when asked about the abuse she stated the privacy curtain was pulled and she heard CNA A ask Resident #1 why you bit me. CNA B stated Resident #1 did not say anything and CNA A slapped her once with her hand across her face and then in a few minutes slapped her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 6 of 8 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 455351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy Nursing and Rehabilitation 2817 Kent Street Bryan, TX 77802 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 again across the face. She stated she was behind the privacy curtain and could witnessed CNA slap Resident #1. CNA B stated she was expected to ask CNA A to leave the room and she was required to immediately report it. She stated Resident #1 did not have any blood on her face. CNA B stated she did not like CNA A, and she did not want to work with her, and the staff coordinator refused to move her to another hall that day. She stated she did not care what happened with CNA A and she hoped she got into trouble. CNA B stated when she came to work, she was moved to another hall, and they did not work together. She stated she was terminated, and she was glad CNA A was reported to the state and she wanted CNA A to lose her license and go to jail for 20 years and there was some other staff she wished would lose their license and go to jail. CNA B stated if anything was said about her not giving the same version of what exactly happened with Resident #1, she stated she would report these people and say they was lying on her. In an interview on 12/07/2023 at 3:10 PM, Human Resource Coordinator stated CNA B came to my office and stated she had witnessed CNA A slap Resident #1 on the face. She stated she did not know why CNA B came to her about the allegation. She stated when I explained to her, they needed to go to the front and talk to the Administrator and Director of Nurses she did not want CNA A observing her speaking to the Administrator or the Director of Nurses. When asked why the Administrator and Director of Nurses was not called to come to your office. She stated she did not think about having them come to her office. She stated she went to the Director of Nurses immediately and informed her of what was reported by CNA B. She stated the Director of Nurses informed the Administrator and they began interviewing staff. She stated if there were any abuse allegations against staff, she would be aware of any allegations that was true. The Human Resource Coordinator stated she was not aware of CNA A abusing a resident. She stated she would know if anyone had been found guilty of abusing a resident. She also stated the information of abuse to a resident from a staff would be placed in the staff personnel file and she was responsible for this duty. In an interview on 12/07/2023 at 3:40 PM, the Administrator stated he had found out about the alleged abuse of Resident #1 within 15 minutes of it being reported to the Director of Nurses. He stated he was in the facility but was not in his office. The Administrator stated the Director of Nurses interviewed the staff involved with the abuse allegation and suspended CNA A. He stated after their investigation on 10/18/2023 it was determined abuse did not occur. The administrator stated he did not think about reporting it to the State due to not finding any merit to the allegation. He stated he now realized he was required to report it to the state through tulip website. He stated he made a mistake by not reporting the abuse allegation. The Administrator also stated if the facility did not report abuse allegations to the state there may be some negative outcome by not having it investigated by a surveyor. He stated the facility staff may miss something during the investigation and a state surveyor would have a different perspective on how to follow up on the facilities investigation. He stated there was a possibility the facility may miss something in the investigation He stated it was expected to be reported and he just failed not to report the abuse allegation on Resident #1. Attempted to interview the Social Worker three times on 12/07/2023 throughout the day and she was not in her office the three times attempted to interview her. In an interview with the administrator on 12/07/2023 at 12:35 PM requested to interview the Social Worker in the conference room. The Social Worker never came to the conference room for interview. The Social Worker was in the facility according to the employee list of all staff in the facility on 12/07/2023. In an interview with the administrator on 12/07/2023 at 3:40 PM requested to interview the Social (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 7 of 8 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 455351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy Nursing and Rehabilitation 2817 Kent Street Bryan, TX 77802 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 Worker in the conference room. The Social worker was never in her office when attempted to visit with her. Level of Harm - Minimal harm or potential for actual harm Record review of the Facilities Abuse Reporting and Investigation Policy and Procedure (no date) reflected all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse will also be reported. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 8 of 8