Health inspection·March 29, 2024

F 0638 assessment will be completed and signed by the interdisciplinary Team ember that gathered the information during the 7-day look back period of the Assessment Reference Date. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 2 of 24 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 03/29/2024 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations listed in the findings, the facility failed to ensure all Pre-admission Screening and Resident Review (PASARR) Level I Screening for residents diagnosed with mental illness were accurate and residents were provided with a PASARR Level II Screening for 2 of 2 resident's (Resident #42 and Resident #55) reviewed for PASARR coordination. Residents Affected - Some The facility failed to ensure Resident #42-Level 1 screening dated 10/05/2020 - listed no and Resident #55 PASARR-Level 1 screening dated 11/01/2022 - listed no PASARR Level 2 evaluation. This failure could place residents at risk for not receiving necessary mental health services, causing a decline in mental health. Findings included: Record review of Resident #42's face sheet dated 03/29/2024 revealed a [AGE] year-old woman admitted on [DATE]. Resident #42 had diagnoses which included spinal stenosis-lumbar region without neurogenic claudication (an abnormal narrowing of the spinal canal or neural foramen that results in pressure on the spinal cord or nerve roots), unspecified dementia- unspecified severity- without behavioral disturbancepsychotic disturbance- mood disturbance- and anxiety (A group of symptoms that affects memory, thinking and interferes with daily life), hyperlipidemia- unspecified (abnormally high levels of any or all lipids or lipoproteins in the blood), bipolar disorder- unspecified, essential (primary) hypertension (high blood pressure), and schizoaffective disorder-unspecified (mental disorder characterized by abnormal thought processes and an unstable mood). Record review of Resident #42's MDS assessment dated [DATE] reflected a BIMS score that indicated moderate cognitive impairment. Section I of the MDS marked Schizophrenia (schizoaffective and schizophreniform disorders). Record review of Resident #42's care plan last revised 02/06/2024 reflected: [Resident #42] has a diagnosis of schizophrenia. The relevant interventions included, administer my medications as ordered by my physician, approach me in a calm manner, assist me with some of my ADL's, encourage me to participate in the facilities daily activities, have the pharmacy consultant to review my psychotropic medications monthly and as needed. Resident #42's care plan also reflected, [ Resident #42] is at risk for side effects from psychotropic drug use. The relevant interventions were, discuss potential side effects of a drug with me, monitor for orthostatic hypotension/ tachycardia, monitor me for signs of extrapyramidal symptoms and document if applicable, monitor my behavior daily and as needed, monitor my bowel elimination patter and report any abnormalities to my physician, and observe me for adverse side effects, document and report to physician. Record review on 03/29/2024 of the MAR reflected an active medication for Seroquel Oral Tablet 50 MG (Quetiapine Fumarate); Give 1 tablet by mouth at bedtime related to schizoaffective disorder, unspecified. Order date, 08/09/2023 1626 (4:26 PM). Record review of Resident #42's PASARR-Level 1 screening dated 10/05/2020 read in part, Is there evidence or an indicator this is an individual that has a Mental Illness? The answer was, No. Record review of Resident #42's care plan initiated 10/05/2020 reflected RESOLVED: Review PASARR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 3 of 24 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 03/29/2024 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 0645 results for Level II indicators and complete as needed. Revised and resolved 03/06/2021. Level of Harm - Minimal harm or potential for actual harm An observation and interview on 03/29/2024 at 12:00 PM with the MDS Coordinator, she stated Resident #42 was negative for PASARR on admission. MDS Coordinator was observed looking at the PASARR Level 1 screening for Resident #42 and said that it was wrong, and she would have to redo it due to the Resident #42 having a diagnosis of schizoaffective disorder. The MDS Coordinator stated, it must have gotten missed somehow when she came in. She stated she would correct Resident #42's so she could be reviewed and potentially picked up for PASARR services. The MDS Coordinator said it was the MDS Coordinators responsibility to ensure accuracy, she said, the MDS at the time could have looked at the diagnosis while combing through and caught the error. She said that a negative outcome of this error was Resident #42 could have missed out on additional services needed if MHMR evaluated Resident #42 and decided to pick her up for PASARR services. Residents Affected - Some An interview on 03/29/2024 at 01:40 PM with the Administrator, he stated it was his expectation that residents are receiving the proper care in the facility. He said it was the MDS coordinators responsibility to ensure accuracy of PASARR assessments upon resident admissions. The Administrator said there are currently two MDS coordinators, but they also have staff that can assist such as the social worker. The Administrator said an incorrect PASARR screening would result in residents not receiving proper care and could also affect payments. Record review of Resident #55's face sheet dated 03/29/2024 revealed a [AGE] year-old woman admitted on [DATE]. Resident #55 had diagnoses which included Cerebral Infarction, Unspecified (Various blood vessels in the neck and brain supply blood to the brain. In your case, not enough blood was getting through certain blood vessels in your brain.), Hemiplegia, Unspecified Affecting Left Nondominant Side (a symptom that involves one-sided paralysis.), Aphasia Following Cerebral Infarction (a disorder that affects how you communicate.), Dysphagia Following Cerebral Infarction (disruption of bolus flow through the mouth and pharynx.), Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety (a person is presenting signs and symptoms of dementia and has a dementia diagnosis, but they lack any symptoms of behavioral disturbances.), Anxiety Disorder, Unspecified (a diagnosis that is characterized as significant anxiety or phobias without the exact criteria for any other anxiety disorders.), Schizoaffective Disorder, Unspecified (a mental illness that can affect your thoughts, mood and behaviors.), Insomnia, Unspecified (a common sleep disorder that can make it hard to fall asleep or stay asleep.) Record review of Resident #55's MDS assessment dated [DATE] reflected a BIMS score of 13 but it was noted to Overwrite BIMS score to 99 due to resident unable to complete the interview. Record review of Resident #55's care plan last revised 03/04/2024 reflected: [Resident #55] has a diagnosis of schizoaffective. The relevant interventions were, administer my medications as ordered by my physician, assist me with some of my ADL's, have the pharmacy consultant to review my psychotropic medications monthly and as needed, I need continuity with my care, monitor me for the side effects of my psychotropic medications daily, notify my physician of any significant changes. Resident #55's care plan also reflected, The relevant interventions were, activities to visit with me and help me plan meaningful activities, allow me to verbalize my feelings and listen in non-judgmental manner, evaluate for environmental changes to enhance my mood, evaluate my effectiveness of medication, need a pharmacy consultant review of medication use and gradual dose reductions as appropriate, monitor me for patterns of target behaviors. Record review on 03/29/2024 of the MAR reflected an active medication Risperdal Oral Tablet 1 MG (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 4 of 24 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 03/29/2024 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 0645 Level of Harm - Minimal harm or potential for actual harm (Risperidone); Give 1 tablet by mouth at bedtime related to Schizoaffective Disorder, Unspecified. Order date 8/16/2023 Record review of Resident #55's PASARR-Level 1 screening dated 11/01/2022 read in part, Is there evidence or an indicator this is an individual that has a Mental Illness? The answer was, No. Residents Affected - Some An interview on 03/29/2024 at 9:20 AM with the MDS Coordinator, she stated Resident #55 was negative for PASARR on admission. MDS Coordinator was observed looking at the PASARR Level 1 screening for Resident #55 and said that it was wrong, and she would have to redo it due to Resident #55 having a diagnosis of schizoaffective disorder. The MDS Coordinator stated, it must have gotten missed somehow when she came in. She stated that was not her primary diagnosis. The coordinator stated whoever processed the information for the resident they just saw dementia and put that on there. She stated she would correct Resident #55 so she could be reviewed and potentially picked up for PASARR services. The MDS Coordinator said it was the MDS Coordinators responsibility to ensure accuracy. She said that a negative outcome of this error was Resident #55 could have missed out on additional services needed. An interview on 03/29/2024 at 01:40 PM with the Administrator, he stated it was his expectation that residents are receiving the proper care in the facility. He said it was the MDS coordinators responsibility to ensure accuracy of PASARR assessments upon resident admissions. The Administrator said there are currently two MDS coordinators, but they also have staff that can assist such as the social worker. The Administrator said an incorrect PASARR screening would result in residents not receiving proper care and could also affect payments. Review of the facility's undated policy PASARR (Resident Review) Policy and Procedure reflected in part, PASARR requires that: The facility shall coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid to the maximum extent practicable to avoid duplicate testing and efforts. Review of the facility's undated policy PASARR (Resident Review) Purpose reflected in part, PASARR, is a federal requirement to help ensure that individuals who has a mental disorder or intellectual disability are not inappropriately placed in nursing homes for long term care. PASARR requires that: 1. All applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability. 2. Be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3. Receive the services they need in those settings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 5 of 24 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 03/29/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for one resident (Resident #94) of eight reviewed, in that: A) The facility failed to ensure Resident #94's Comprehensive Care Plan reflected a revision for his isolation precautions related to MRSA (Methicillin Resistant staphylococcus aureus) and his current skin condition. B) The facility failed to ensure Resident #46's Comprehensive Care Plan reflected his use of a indwelling urinary catheter. This failure could place a resident at risk for errors in provider care, poor wound healing/worsening wound condition, and the potential spread of infection. Findings included: A) Review of Resident #94's Face sheet dated 03/28/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses Huntington's Disease (is a rare, inherited disease that causes the progressive breakdown (degeneration) of nerve cells in the brain.), Cerebral Infarction (the pathologic process that results in an area of necrotic tissue in the brain. It is caused by disrupted blood supply (ischemia) and restricted oxygen supply (hypoxia).), Aphasia (A comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to the specific area in the brain.) and Cachexia (is a wasting disorder that causes extreme weight loss and muscle wasting and can include loss of body fat.) Review of Resident #94's Quarterly MDS assessment dated [DATE] reflected Resident #94 was assessed to have BIMS score of nine indicating moderate cognitive impairment. Resident #94 was assessed to be dependent on staff for all ADLs. Resident #94 was assessed to not have pressure ulcers or isolation for active infectious disease. Review of Resident #94's consolidated physician orders dated 03/28/2024 reflected an order for Contact isolation for MRSA with the start date of 03/05/2024. Further review of Resident #94 consolidated physician orders reflected no orders for pressure ulcer care. Review of Resident #94's weekly skin assessment dated [DATE] reflected resident was assessed to not have pressure ulcers. Review of Resident #94's comprehensive care plan reflected a focus area dated 10/23/2023 I have a deep tissue injury to my right malleolus and left malleolus. Further review of Resident #94's care plan reflected an entry dated 10/23/2023 I have a Stage 3 pressure injury to sacrum. Resident #94 care plan further reflected a focus area dated 12/27/2023 I require isolation due to COVID. Resident #94's care plan did not reflect a plan of care for MRSA isolation. Observation on 03/27/2024 at 10:30 AM revealed a container with isolation equipment outside of Resident #94's room and a sign indicating he was in contact isolation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 6 of 24 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 03/29/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation and interview on 03/27/2024 at 10:33 AM revealed Resident #94 in room alert. Resident #94 was having difficulty finding his words and was not able to be interviewed. Resident #94's sitter was in the room. She stated Resident #94 was in isolation related to MRSA in his J-Tube site (Jejunostomy tube-J-tube is a medical device, inserted into the jejunum (the middle part of the small intestine). Its aim is to provide the necessary medications and nutrition.) The sitter further stated Resident #94 no longer had pressure sores that they were all healed. In an interview on 03/29/2024 at 09:51 AM The MDS coordinator stated after reviewing resident #94's care plans that she should have updated the care plan to remove the pressure ulcer wounds and should have updated to the care for the current isolation he was on. She stated when he came in, he had COVID then he developed MRSA later after his J-tube surgery. The MDS coordinator stated she just missed the changes and should have updated his care plan to ensure the nursing staff have the correct information to provide the proper care. B) Review of Resident #46's face sheet dated 03/28/2024 reflected an [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses Acute Kidney Failure, (A condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days. Symptoms include legs swelling and fatigue.) Benign Prostatic Hyperplasia ( A condition in which the flow of urine is blocked due to the enlargement of prostate gland. The symptoms include increased frequency of urination at night and difficulty in urinating.) and Hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms varies from person to person and generally include unexplained fatigue and headache.) . Review of Resident #46's admission MDS dated [DATE] reflected Resident #46 was assessed to have a BIMS score of nine which reflected mild cognitive impairment. Resident #46 was assessed to require extensive assist with ADLs. Resident #46 was assessed to not have an indwelling catheter. Review of Resident #46's comprehensive care plan reflected a focus area dated 03/01/2024 I am incontinent of urine. Further review of Resident #46's care plan reflected no entry for an indwelling catheter. Observation on 03/27/2024 at 1:45 PM revealed Resident #46 in room in bed. The Treatment Nurse was in room to perform wound care. The Treatment Nurse removed Resident #46's cover to reveal an indwelling catheter. No catheter secure device was observed, and the catheter tubing was not stabilized to Resident #46's leg old tape was noted to be attached to the catheter tubing. In an interview on 03/28/2024 at 4:03 PM the DON stated Resident #46 did not have an order for his indwelling catheter she stated at some point it was removed then the staff must have reinserted. The DON stated he should defiantly have a physician order to ensure he is getting the proper care. The DON stated she expected all residents with indwelling catheters to have physician orders for the catheters, plans of care for the catheter and they should have secure Cath's in place to prevent trauma or infection. In an interview on 03/29/2024 at 10:15 AM the DON stated she expected the resident's care plan to be updated whenever the residents have a change in their treatment plan to ensure they are receiving the proper care. She stated by not updating the plan of care it could lead to decline in resident's skin condition or the spread of infection. Review of the facility's policy Care planning policy and procedure (not dated) reflected .Each (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 7 of 24 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 03/29/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm resident's care plan will remains current and inform staff of resident's needs, strengths, goals and approaches Resident's care plan will be reviewed with the resident, responsible party and interdisciplinary team quarterly and as needed Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 8 of 24 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 03/29/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for two of six residents reviewed for catheter care (Resident #4 and Resident #46). A) The facility failed to ensure Resident #4's had a plan of care for her catheter, that it was secured to her body with a catheter secure device and failed to monitor her catheter care per the facility policy. B) The facility failed to ensure Resident #46's catheter was ordered by a physician, had a plan of care and was secured to his body with a catheter secure device per the facility policy. This failure to secure catheters placed residents with urinary catheters at risk for traumatic removal and catheter acquired infections. Findings included: A) Review of Resident #4's Face sheet dated 02/02/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Diabetes Mellitus Type 2 (A condition results from insufficient production of insulin, causing high blood sugar.) Traumatic Brain injury (A head injury causing damage to the brain by external force or mechanism. It causes long term complications or death.), and Paraplegia (is an impairment in motor or sensory function of the lower extremities.). Review of Resident #4's admission assessment dated [DATE] reflected Resident #4 was assessed to have a BIMS score of 3 indicating severe cognitive impairment. Resident #4 was assessed to be dependent on staff for all ADLs. Resident was assessed to not have an indwelling catheter. Review of Resident #4's comprehensive care plan reflected no plan of care for Resident #4's indwelling catheter. Review of Resident #4's consolidated physician orders reflected an order with a start date 02/25/2025 Maintain urinary catheter. Monitor Cath care every shift and as needed. Review of Resident #4's Nursing MAR dated March 2024 reflected an entry to maintain urinary catheter and to monitor catheter every shift and PRN. The nursing MAR did not have any documented signatures for monitoring every shift. Observation on 03/28/2024 at 09:43 AM revealed Resident #4 in her room in bed. The Treatment Nurse was setting up to perform wound care. The Treatment Nurse removed Resident #4's covers to reveal Resident #4 had an indwelling catheter. No catheter secure device was observed the catheter tubing was not stabilized to Resident #4's leg. In an interview on 03/28/2024 the Treatment Nurse stated that Resident #4 should have a catheter secure device in place to ensure Resident #4's catheter in not pulled on during care which could cause pain, and trauma to the urethra. The Treatment Nurse stated the Charge Nurse was responsible for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 9 of 24 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 03/29/2024 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 0690 monitoring resident catheters and catheter care. Level of Harm - Minimal harm or potential for actual harm In an interview on 03/29/204 at 9:51 AM the MDS Coordinator stated Resident #4 did not have a plan of care for her indwelling catheter. The MDS coordinator stated she did not know why she did not have a plan of care for the catheter, but she defiantly needed one. She stated care could be missed by staff which could lead to a urinary infection. Residents Affected - Few B) Review of Resident #46's face sheet dated 03/28/2024 reflected an [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses Acute Kidney Failure, (A condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days. Symptoms include legs swelling and fatigue.) Benign Prostatic Hyperplasia (A condition in which the flow of urine is blocked due to the enlargement of prostate gland. The symptoms include increased frequency of urination at night and difficulty in urinating.) and Hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms varies from person to person and generally include unexplained fatigue and headache.) Review of Resident #46's admission MDS dated [DATE] reflected Resident #46 was assessed to have a BIMS score of nine which reflected mild cognitive impairment. Resident #46 was assessed to require extensive assist with ADLs. Resident #46 was assessed to not have an indwelling catheter. Review of Resident #46's comprehensive care plan reflected a focus area dated 03/01/2024 I am incontinent of urine. Further review of Resident #46's care plan reflected no entry for an indwelling catheter. Review of Resident #46's consolidated physician orders reflected no order for an indwelling catheter. Review of Resident #46 Nursing MAR reflected an entry dated 03/07/2024 D/C (discontinue) catheter. Monitor for output 6-8 hours. Re-catheterize if greater than 300 cc leave Cath in place . Further review reflected no other entries related to indwelling catheters. Observation on 03/27/2024 at 1:45 PM revealed Resident #46 in room in bed. The Treatment Nurse was in room to perform wound care. The Treatment Nurse removed Resident #46's cover to reveal an indwelling catheter. No catheter secure device was observed, and the catheter tubing was not stabilized to Resident #46's leg old tape was noted to be attached to the catheter tubing. In an interview on 03/27/2024 at 1:47 PM the Treatment Nurse stated the Resident #46 should have his indwelling catheter secured to his leg to prevent the catheter from pulling. In an interview on 03/27/2024 at 1:48 PM CNA H stated regarding Resident #46 His tape always coming undone, it is like that all the time. In an interview on 03/28/2024 at 10:38 AM LVN D stated he was in charge of ensuring the catheter secures were in place on his hall. He stated he was the nurse for Resident #4 and #46. He stated he had not checked that care was done on his hall he had not gotten around to it yet. LVN D stated that all indwelling catheters should have catheter secure devices in place to ensure the catheters are not pulled on which could cause trauma or infection. In an interview on 03/28/2024 at 4:03 PM the DON stated Resident #46 did not have an order for his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 10 of 24 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 03/29/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indwelling catheter she stated at some point it was removed then the staff must have reinserted. The DON stated he should defiantly have a physician order to ensure he is getting the proper care. The DON stated she expected all residents with indwelling catheters to have physician orders for the catheters, plans of care for the catheter and they should have secure Cath's in place to prevent trauma or infection. Review of the facility's policy Catheter care, indwelling catheter policy and procedure not dated reflected Purpose 1. To prevent infection. 2. To reduce irritation .catheter care should be provided daily or as needed. Catheter should be changed according to CDC guidelines or as ordered by the physician Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009) (cdc.gov) . Review of the CDC guidelines for prevention of catheter associated urinary tract infections referred to in the policy dated 06/06/2019 reflected .Properly secure indwelling catheters after insertion to prevent movement and urethral traction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 11 of 24 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 03/29/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the safe handling, humidification, cleaning, storage, and dispensing of oxygen for respiratory care services provided to 3 of 3 residents (Resident 35, 53, and 56) reviewed for respiratory care. Residents Affected - Few The facility failed to ensure Residents oxygen tubing was dated to ensure it was changed weekly for 3 residents (Resident 35, 53, and 56) as ordered by the physician and as verbally reported to be the facility policy by DON. The facility failed to have a written policy to ensure the safe handling, humidification, cleaning, storage, and dispensing of oxygen on 03/29/2024 at 10:10 a.m. A policy is required per guidelines. The facility failed to ensure that the Oxygen setting matched the physicians order for 1 of the 3 residents. Oxygen set at 4 Liters per minute instead of the 3 Liters per minute ordered. This failure placed the residents at risk of developing a respiratory infection from contamination of the tubing and humidifier water. Findings include: A review of Resident 35's face sheet dated 03/28/2024 reflected she is an [AGE] year-old female with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) which blocks air flow in the lungs. Her other diagnoses are Malnutrition, Anxiety, Heart Failure, and Hypertension. A review of Resident 35's Minimum Data Set (MDS) dated [DATE] reflected she has a BIMS (Brief Interview for Mental Status) Score that indicates she was cognitively competent. A review of Resident 35's Care Plan reflected on 05/19/2022 a focus area was initiated for shortness of breath associated with her COPD diagnosis. A review of Resident 35's Orders reflected current orders for the month of March 2024 are: Clean Oxygen (O2) filter, cannula tubing and humidified water weekly at bedtime every Thursday and Oxygen run at 2-3 Liters via nasal cannula as needed to keep Oxygen saturation levels >90%. A review of Resident 53's face sheet dated 03/28/2024 reflected he was a [AGE] year-old male with diagnoses of Respiratory Failure, Diabetes, Morbid Obesity, Cerebrovascular Disease. A review of Resident 53's MDS dated [DATE] reflected he has a BIMS (Brief Interview for Mental Status) Score of 15 which indicates he is cognitively competent. A review of Resident 53's Care Plan reflected a Focus initiated on 01/02/2024 for resident's respiratory failure with a goal to keep respiratory problems at a minimum level. A review of Resident 53's Orders reflected current orders for month of March 2024 are: Clean Oxygen (O2) filter, cannula tubing and humidified water weekly at bedtime every Saturday and Oxygen run at 2-3 Liters via nasal cannula as needed to keep Oxygen saturation levels >90%. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 12 of 24 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 03/29/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm A review of Resident 56's face sheet dated 03/28/24 reflected she was a [AGE] year-old female with diagnoses of Dementia, Anxiety, Malnutrition, Hypertension. A review of Resident 56's MDS dated [DATE] reflected she has a BIMS (Brief Interview for Mental Status) Score of 00 which indicates she was severely cognitively impaired. Residents Affected - Few A review of Resident 56's orders reflected current orders for the month of March 2024 are: Oxygen run at 2-3 Liters via nasal cannula as needed to keep Oxygen saturation levels >90%. Observation on 03/27/2024 at 11:00 a.m. revealed Resident #35 has an oxygen concentrator machine set at 3 liters per minute and she was wearing her nasal cannula. Neither the tubing nor the humidifier water bottle has a date indicating when it was last changed. Observation on 03/27/2024 at 11:19 a.m. revealed Resident #56 has an oxygen concentrator machine with her oxygen tubing hanging on the machine without a bag or cover. Neither the tubing nor the humidifier water bottle had a date indicating when it was last changed. Observation on 03/27/2024 at 11:20 a.m. revealed Resident #53 has an oxygen concentrator machine set at 4 liters per minute and he is wearing the nasal cannula. Neither the tubing nor the humidifier water bottle has a date indicating when it was last changed. Observation on 03/28/2024 at 11:09 a.m. revealed Resident #35 has an oxygen concentrator machine set at 3 liters per minute and she is wearing her nasal cannula. Neither the tubing nor the humidifier water bottle has a date indicating when it was last changed. Observation on 03/28/2024 at 11:20 a.m. revealed Resident #53 has an oxygen concentrator machine set at 4 liters per minute and he is wearing the nasal cannula. Neither the tubing nor the humidifier water bottle has a date indicating when it was last changed. In an interview on 03/28/2024 at 4:12 p.m. with LVN E, she stated the night shift nurses normally changes oxygen tubing every 7 days, but she would confirm the policy. When interview was resumed on 03/28/2024 at 04:15 p.m., LVN E confirmed that after checking oxygen tubing on residents35, 53, and 56 that she could not find dates or initials on the tubing or water bottles. She stated that tubing should have been changed to prevent infection and the outcome of not changing it could be respiratory infections. In an interview on 03/29/2024 at 09:04 a.m. LVN-C she stated nurses change oxygen tubing weekly. The order shows on the Medication Administration Record (MAR). She stated they write their initials on the cup with water and they initial and date the oxygen tubing to indicate when changed. She further stated the tubing is changed to prevent infection. She stated the failure to change it could cause respiratory infections. In an interview on 03/29/2024 at 09:21 a.m. with CNA-G, she stated that not changing oxygen tubing could cause respiratory infections, aspiration, humidifier water would get nasty. She stated she would tell the nurse if tubing was contaminated on the floor. In an interview on 03/29/2024 at 09:37 a.m. with LVN E, she stated the reason to change oxygen tubing is to prevent infection. The result of not changing the tubing could be respiratory infections (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 13 of 24 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 03/29/2024 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 0695 for residents. Level of Harm - Minimal harm or potential for actual harm . Residents Affected - Few In an interview on 03/29/2024 at 10:10 a.m. with DON, she stated the 02 (oxygen) tubing change policy was to change every Sunday night weekly. She stated tubing is changed for infection control purposes and if not changed it could cause pneumonia for residents. A review of the undated Oxygen Policy labeled Oxygen Administration Policy and Procedure and identified in footnote as Legacy Management Group Page 1 of 2 and Page 2 of 2 failed to specify the safe handling, humidification, cleaning, storage, or dispensing of oxygen after the initial set-up. The policy does not indicate when tubing should be changed for infection control. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 14 of 24 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 03/29/2024 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews , and record review the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive and at a safe and appetizing temperature for residents who consumed foods orally from the only kitchen in the facility in that: Residents Affected - Some 1. The kitchen test tray of the lunch meal foods was burnt, inedible, and unappealing. 2. The facility failed to provide palatable food that was attractive or appetizing to residents' who complained the food did not look or taste good. This failure could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life. The findings included: 1. An observation at 03/29/2024 at 12:40 PM a lunch test tray was sampled. The test tray consisted of country fried steak with cream gravy, mac and cheese, green beans, and corn bread. On the side there was a small bowl of fruit cobbler, a glass of water, and a glass of sweet tea. Initial observation of the meal the food looked appealing except for the mac and cheese; the cheese appeared cold and dry. The country fried steak was burned and had an overwhelming burned/smoke taste to it which made it inedible. The mac and cheese tasted cold and dry as it visually appeared and had very little flavor. The green beans were lightly seasoned and had a pleasant taste, and the corn bread was cooked well- not overbaked, had a nice consistency, and pleasant taste. The fruit cobbler had a metallic aftertaste, verry little flavor from the batter crust, and was a mushy consistency. 2. a. Record review of Resident #67's face sheet dated 03/29/2024 revealed a [AGE] year-old male admitted [DATE] with a diagnosis of chronic atrial fibrillation unspecified (irregular heart rhythm), unspecified protein calorie malnutrition, and chronic obstructive pulmonary disease unspecified (progressive lung disease characterized by long term respiratory symptoms and airflow limitation). Record review of Resident #67's MDS assessment dated [DATE] reflected a BIMS score of 14 suggesting cognition is intact. Record Review of Resident #67's clinical physician orders reflected an active order started on 12/16/2022 for NAS/NCS, regular texture, regular fluid consistency diet. An interview on 03/29/2024 at 12:55 PM with Resident #67 he stated his lunch was not good. He said, the chicken fried steak was scorched, it tasted burnt and looked burnt. He described flipping his steak over and seeing black tar under his steak. He described the green beans he ate tasted fresh out (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 15 of 24 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 03/29/2024 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 0804 of the can. He said it was not good at all. Level of Harm - Minimal harm or potential for actual harm b. Record review of Resident #47's face sheet dated 03/29/24 revealed a [AGE] year-old male admitted [DATE] with a diagnosis of other sequelae (any complication or condition that results from a pre-existing illness, injury, or medical intervention) following unspecified cerebrovascular disease (group of disorders that affect the blood vessels and blood supply to the brain), essential (primary) hypertension (high blood pressure), and unspecified protein-calorie malnutrition. Residents Affected - Some Record review of Resident #47's MDS assessment dated [DATE] reflected a BIMS score of 15 suggesting cognition is intact. Record Review of Resident #47's clinical physician orders reflected an active order started 10/08/2021 for NAS/NCS, regular texture, regular fluid consistency diet. An interview on 03/29/2024 at 12:58 PM with Resident #47 he stated his steak tasted scorched. c. Record review of Resident #41's face sheet dated 03/29/2024 revealed a [AGE] year-old female admitted on [DATE] with a diagnosis of multiple sclerosis (disease that affects the central nervous system), unspecified protein calorie malnutrition, and quadriplegia unspecified (the paralysis of both arms and legs due to various conditions, such as spinal cord injury, stroke, or cerebral palsy). Record review of Resident #41's MDS assessment dated [DATE] reflected a BIMS score of 12 suggesting moderate cognitive impairment. Record review of Resident #41's clinical physician orders reflected an active order started on 10/03/2022 for a regular diet, regular texture, regular fluid consistency. An interview on 03/29/2024 at 01:10 PM with Resident #41 she said that the CNA who helped feed her made a statement that the steak smelled burnt. She said she did not remember the staff member's name. She said she remembered the dessert was something with peaches but was not good. d. Record review of Resident #16's face sheet dated 03/29/2024 revealed a [AGE] year-old female admitted [DATE] with a diagnosis of cerebral infarction (death of tissue in the brain, also called a stroke), iron deficiency anemia unspecified, and dehydration. Record review of Resident #16's MDS assessment dated [DATE] reflected a BIMS score of 15 suggesting cognition is intact. Record review of Resident #16's clinical physician orders reflected an active order started 04/26/2023 for a NAS/NCS diet, regular texture. An interview on 03/29/2024 at 01:15 PM with Resident #16, she said the steak was burnt. She said, I asked for another one, but the staff said they are all burnt, and I asked why they served it then. An Interview on 03/29/2024 at 01:20 PM with the DM she said it was her expectation that food looks appealing, was edible, and something that the residents enjoy. She said a potential negative outcome is the residents wouldn't want to eat the food provided. The DM said she tries to eat the food daily to check it but did not have it that day on 03/29/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 16 of 24 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 03/29/2024 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete An Interview on 03/29/2024 at 01:40 PM with the Administrator, he stated it was his expectation that kitchen staff provide quality and nutritional food to the residents. He said it should look presentable because we also eat with our eyes and the taste should be pleasant. The administrator stated that having food that was unappealing and inedible can lead to clinical negative outcomes with the residents such as weight loss because they aren't eating the food. He stated that having bad food can also lead them to not be as happy and affect their social well-being. Event ID: Facility ID: 455351 If continuation sheet Page 17 of 24 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 03/29/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen and food sanitation. 1. The facility failed to label and date all food items located in the refrigerators and freezer. 2. The facility failed to ensure damaged or dented canned food items were kept in a separate designated area and not used. 3. The facility failed to ensure kitchen staff practiced proper hand hygiene and glove use when preparing food. 4. The facility failed to ensure kitchen staff cleaned and sanitized the blender in between pureed food items. 5. The facility failed to ensure staff used proper hygienic practice when handling food and feeding a resident. 6. The facility failed to ensure kitchen staff were knowledgeable about food holding temperatures, and the appropriate device used to measure internal temperature . These failures could place residents at risk for food contamination and foodborne illness. Findings included: During the initial tour of the kitchen on 03/03/24 at 09:43 AM the following was observed: 1. Reach in refrigerator contained a tray with individual cups prepared with peaches and apple sauce covered with saran wrap, neither tray or cups were labeled or dated. 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 18 of 24 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 03/29/2024 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 0812 Reach in freezer contained a bag of waffles in a clear bag taped closed, no label or date. Level of Harm - Minimal harm or potential for actual harm 3. Walk in freezer contained seven bags of meat not labeled or dated. Residents Affected - Many An interview and observation on 03/27/24 at 10:10 AM with the DM, she stated the tray that contained peaches and apple sauce were prepared the night of 03/26/24 and said they were supposed to have been labeled and dated. She said it was her expectation that all items in the refrigerators and freezers contain labels saying what it is, and the dates received/ prepared, and day they expire. The DM stated that she did not know when the seven bags of meat were placed in the freezer and could not visually identify what two of the bags were but said the other five were bags of chicken. The DM was observed pulling the seven bags of meat out of the walk-in freezer and throwing them away. The DM stated without labels there is no way of knowing what the item is, or when it should be thrown out. She said having items in the refrigerator/ freezer past its expiration date could make residents sick. An observation on 03/27/24 at 11:40 AM the SLP was observed in the dining room assisting a resident with his feeding. The SLP was observed touching her clothing and putting her hand in her pocket and then touching the resident's food, beverage cup, and straw as she assisted with his meal. An interview on 03/27/24 at 11:55 AM the SLP stated nobody ever told her she was not supposed to touch her clothing or other items while assisting a resident with meal services. She also stated that she is aware a potential negative outcome to touching her clothing or other contaminated items and then feeding a resident could cause her to pass something along if she had something on her clothing that could cause food contamination. An interview and observation on 03/28/24 at 10:25 AM [NAME] A was observed using a 6-pound, 10 oz (3.01 kg) can labeled mixed vegetables that was deeply dented with the dent spanning the entire front portion of the can horizontally forming a crease; additional dents to the bottom seam were also observed. When asked if it was safe to use the dented can [NAME] A said, no not really but was observed continuing to use the can to prepare the turkey and mixed vegetable puree. [NAME] A was then observed preparing the pureed bread followed by pureed beets with milk without washing or sanitizing the blender in between each item. [NAME] A was observed leaving the workstation in the middle of pureeing the beets with milk and touching the door going into the staff locker room. [NAME] A was then observed using her gloved hand to scoop out the pureed beets with milk. [NAME] A stated she did not have a spatula and was then observed taking a visibly soiled metal fork from a visibly dirty cart and using it to scrape the remainder of the pureed beets and milk from the blender after only rinsing the fork with plain water in a two compartment sink without using soap or sanitizer to clean the fork. During this pureed food prep, [NAME] B was observed cutting what she said were apple orchid bars and touching her clothing with her gloved hands at different times. [NAME] B's badge was also observed dangling over and at one point making contact with the apple orchid bars. [NAME] B was observed then removing her badge and putting it in her shirts front pocket without changing gloves before returning to the apple orchid bars. An interview and observation on 03/28/24 at 11:06 AM [NAME] A and [NAME] B were observed attempting to take internal temperatures of food at the steamtable using an infrared thermometer by scanning the top of the regular texture chicken pot pie. [NAME] B stated that an infrared thermometer is what was normally used, and that a food thermometer with a probe was rarely used except when it came to meat sometimes. [NAME] B was then observed switching thermometers and used the food thermometer with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 19 of 24 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 03/29/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm a probe to complete the temperature checks. [NAME] A stated she believed holding temperature for food was above 200 but then said, no I think it is 120. [NAME] B stated she believed food holding temperatures were supposed to be over 200. After checking the holding temperature of the pureed bread and pureed beats with milk, both temperatures reached 120 degrees Fahrenheit. [NAME] A was observed pulling both from the steam table to reheat. Residents Affected - Many An interview on 03/28/24 at 11:36 AM with the DM she stated she did not know exactly how a dented can could make someone sick but that she was aware they should not be used to prepare meals. The DM stated that it is her expectation that the dented cans are separated and moved to the dented can section in the hall outside of the kitchen. The DM stated that after she was informed a severely dented can was used to make the pureed turkey and mixed vegetables, the puree was pulled from the steam table and none if it was consumed by any of the residents. She said that a new puree containing turkey and peas was prepared and served. An interview on 03/28/24 at 12:59 PM with [NAME] A, she stated that she has been trained to wash and sanitize the blender in between pureed items but said the forgot. She also said forks or other utensils must be washed and sanitized properly before being used. She said a negative outcome to not sanitizing the blender or forks/utensils would be food poisoning which could make the residents sick. [NAME] A said she was also aware she should not have touched unclean surfaces or the door handle to the locker room in the middle of preparing food. She said it could lead to cross contamination. [NAME] A said she was not aware that she could not use dented cans, and she said she did not know what the food holding temperatures were. An interview on 03/28/24 at 01:07 PM with [NAME] B she stated she believed the steamtable holding temperatures were supposed to be above 200 degrees. She stated her last training on temperatures was 3 months ago. [NAME] B stated that she was aware staff were supposed to change gloves after touching unclean surfaces and are not to touch clothing when working with food in order to prevent cross contamination. She stated she realized her badge was getting in the way and touching the food so that's why she took it off and put it in her pocket. An interview on 03/28/24 at 02:34 PM with the DM she stated it is her expectation that gloves are changed after walking away from food or touching anything that could contaminate the gloves. She stated she also expects that staff members wash their hands thoroughly between changing gloves. The DM said they also have a 3 compartment sink and she expects that the blender and utensils are properly cleaned and sanitized in between items. She said failure to change gloves or properly clean the blender/utensils would lead to cross contamination of food which could make residents sick. The DM stated she was not aware of what steamtable holding temperatures should be, and she said she was not ever told she could not use an infrared gun to take internal temperatures of food. An interview on 03/29/24 at 01:40 PM with the Administrator, he stated it is their policy that cans with large dents on the seams should not be used; it could cause the food to be exposed to air which could lead to contamination. The administrator stated it is his expectation that the blender is properly cleaned and sanitized in between uses. He said he expects that temperature checks are performed to regulations and that a probe thermometer is used to check internal temperatures of food. The Administrator said he expects all items are labeled and dated per regulation. He said food should be dated when it arrives and if opened it should be sealed properly, labeled, and dated. He stated that dietary staff should not be touching other items if they are working with food and staff should be removing gloves, washing their hands, and using a new set of gloves in between activities or if the gloves become contaminated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 20 of 24 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 03/29/2024 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 0812 Record review of undated Food Safety and Sanitation Policy and Procedure reflected: Level of Harm - Minimal harm or potential for actual harm Policy: All local, state, and federal standards and regulations are followed to assure a safe and sanitary food service department. Residents Affected - Many Procedure: .All staff will wash their hands just before they start to work in the kitchen and when they have used their hands in an unsanitary way such as smoking, sneezing, using the restroom, handling poisonous compounds, dirty dishes, touching face, hair, other people, etc. .Bulging or leaking cans, cans with sever dents on the seams, or broken containers of food are not used. .All time and temperature control for safety (TCS) leftovers are labeled, covered, and dated when stored. Record review of undated Preventing Foodborne Illness Food Handling Policy and Procedure reflected: Purpose: to provide guidance on proper food handling to avoid foodborne illness. Policy: Food will be stored, prepared, handled, and served so that risk of foodborne illness is minimized. Procedure: .This facility recognizes that the critical factors implicated in foodborne illness are: a. Poor personal hygiene of food service employees. b. Inadequate cooking and improper holding temperatures. c. Contaminated equipment; and d. Unsafe food sources .All food service equipment and utensils will be sanitized according to current guidelines and manufacturers recommendations. Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 21 of 24 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 03/29/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under § 3-202.18. 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under [paragraph] (B) and in [paragraph] (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57°C (135°F) or above, except that roasts cooked to a temperature and for a time specified in [paragraph] 3-401.11(B) or reheated as specified in [paragraph] 3-403.11(E) may be held at a temperature of 54°C (130°F) or above; or (2) At 5ºC (41ºF) or less. 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 22 of 24 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 03/29/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of transmission of communicable diseases and infections for 3 of 3 resident reviewed (Resident #24, #52, and #5) for infection control. Residents Affected - Few The facility failed to ensure MA-F performed proper hand hygiene and failed to ensure MA sanitized equipment for infection control during 03/28/2024 medication pass for Residents #24, #52 and #5. This failure placed residents at risk for development of communicable diseases and infections. Findings included: Review of 03/28/2204 face sheet for Resident 24 reflected he was a [AGE] year-old male admitted [DATE] with diagnoses of Cerebrovascular Disease, Diabetes Type 2, Cerebral Infarction (stroke) with right side paralysis, Congestive Heart Failure and Depression. Review of March 2024 Medication Administration Record for Resident 24 reflects a current order for Metoprolol ER 100miligrams 1 tablet by mouth in the morning. Hold if systolic blood pressure below 100 or diastolic blood pressure below 80 or heart rate below 60. Review of 01/0320/24 MDS (Minimum Data Set) for Resident 24 reflected a BIMS (Brief Interview for Mental Status) score that reflects resident has moderate cognitive impairment. Review of 3/28/24 face sheet for Resident 52 reflected he is a [AGE] year-old male admitted [DATE] with diagnoses of Dementia, Asthma, Malnutrition, Parkinson Disease, right side paralysis, Cerebrovascular Disease. Review of Care Plan for Resident 52 reflected on 05/29/2023 a Care Plan Focus was initiated for risk of infection with a goal to experience no signs/symptoms of infections. Review of 01/26/2024 MDS (Minimum Data Set) for Resident 52 reflected a BIMS (Brief Interview for Mental Status) that reflects resident has moderate cognitive impairment. Review of 03/28/2024 face sheet for Resident 5 reflected she is a [AGE] year-old female admitted [DATE] with diagnoses of Alzheimer's Disease, Chronic Obstructive Pulmonary Disease, Malnutrition, Depression, Hypothyroidism. Review of Care Plan for Resident 5 reflected on 07/30/2023 a Care Plan Focus was initiated for cognitive loss due to Alzheimer's. Review of 02/28/2024 MDS (Minimum Data Set) for Resident 5 reflected a BIMS (Brief Interview for Mental Status) score of 15 which reflects resident is cognitively intact. Observation on 03/28/2024 at 7:32 a.m. revealed MA-F went to Resident 24's bed with a blood pressure cuff to check his vitals. The blood pressure cuff was not cleaned prior to entering the room. She returned to the medication cart and placed the uncleaned blood pressure cuff on the top of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 23 of 24 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 03/29/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication cart. She proceeded to administer his medications then returned to the medication cart to start the next residents' (roommates) medications without washing or sanitizing her hands. Observation on 03/28/2024 at 7:49 a.m. revealed MA-F pulled medications for Resident 52 next without washing or sanitizing her hands. The unclean blood pressure cuff was still on the top of the medication cart on which she was working. She then proceeded to go to the resident 52's bed to administer his medications. She washed her hands after completing this resident's meds. Observation on 03/28/2024 at 8:09 a.m. revealed MA-F pulled medications for Resident 5 next. The uncleaned blood pressure cuff was on the top of the medication cart on which she was working. She proceeded to administer the medications for Resident 5 then washed her hands. In an interview on 03/28/2424 at 08:15 with MA-F, she stated she did not washed hands between Resident 24 and 52. She stated she washes her hands between rooms not between residents. She stated she would clean the blood pressure cuff before the next use. She stated the cuff laying unclean on the medication cart while she is pulling medications for others is an infection control risk. CMA-F agreed the cuff should be cleaned before placing it on the cart and hands should be cleaned between residents for infection control. In an interview on 03/29/2024 at 09:04 a.m. with LVN-C, she stated you should wash or sanitize hand between residents. and before you go in a room. Equipment should be sanitized between residents to prevent transferring infection/germs. She stated the outcome if you do not sanitize could be infection or residents getting sick. In an interview on 03/29/2024 at 09:21 a.m. with CNA-G she stated you should wash hands every room you enter and sanitize between residents. She stated not doing it could cause spread of germs, bacteria, and infections. In an interview on 03/29/2024 at 09:37 a.m. with LVN E, she stated the policy is to hand wash or sanitize hands before and after assisting a resident, performing any procedure, or toileting. She also stated the policy on equipment going from resident to resident is to sanitize with wipes before and after use. She stated if you do not follow the policy, the outcome is spread of infection for equipment or hands. In an interview on 03/29/2024 at 10:10 a.m. with DON, she stated hands should be washed or sanitized between rooms and residents for infection control. If this is not done, the outcome could be spread of infection, disease, and outbreaks for residents. Review of undated policy titled, Hand Hygiene Policy and Procedure reflected cleanse hands between resident direct contact. The policy reflects this is to reduce the spread of infections and prevent cross contamination. The policy further states, Pathogens can contaminate the hands of a staff person during direct contact with the residents or contact with contaminated equipment and environmental surfaces within close proximity of the resident. The policy reflects hand hygiene will be performed l. upon and after coming in contact with a resident's intact skin (e.g., when taking a pulse or blood pressure). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 24 of 24