Health inspection·December 4, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some ordered.Review of the facility Medication Admin Report dated 9/24/2025 at 2:31 pm, reflected Resident #2 had Carbidopa-Levodopa due: on 8/28/2025 between 7:00 and 8:00 am with an administration time of 9:16 am.Review of Resident #2's progress notes revealed there were no notes supporting the late administration of medications on 8/28/2025.Resident #3Review of Resident #3's face sheet dated 9/24/2025 reflected an [AGE] year-old female admitted on [DATE] with diagnoses that included: Parkinson's disease (chronic, progressive brain disorder that affects movement), anxiety disorder, Hypothyroidism (disorder of the thyroid gland) depression and chronic pain syndrome. Face sheet reflected resident was discharge on [DATE].Review of Resident #3's uncategorized MDS assessment dated [DATE] reflected a BIMS assessment had not been completed yet.Review of Resident #3's orders reflected an order dated 8/19/2025: Carbidopa-Levodopa ER Oral Tablet Extended Release 25-100 MG (Carbidopa-Levodopa) Give 2 tablet by mouth three times a day related toPARKINSONISM, UNSPECIFIED, with administration times of 10:00 am, 2:00 pm, and 6:00 pm.Review of Resident #3's care plan reflected it was blank. Resident admitted [DATE] and discharged [DATE].Review of the facility Medication Admin Report dated 9/24/2025 at 2:31 pm, reflected Resident #3 had Carbidopa-Levodopa due:- on 8/20/2025 at 2:00 pm, with an administration time of 3:06 pm.- on 8/20/2025 at 6:00 pm, with an administration time of 10:18 pm.Review of Resident #3's progress notes revealed there were no notes supporting the late administration of medications on 8/20/2025.During an interview on 9/24/2025 at 2:37 pm MA-A stated the 400 hall was her regular hall and she typically works the 6 am to 6 pm shift as a Med Aide. She stated the facility policy allows staff to give medications an hour before or after the posted time. She stated she was familiar with the medication Carbidopa-Levodopa, and it was used to treat Parkinson's disease. She stated this medications helps controls tremors or shaking in the residents and helps with confusion related to the disease process. She stated if the medications were late, the system doesn't require them to put in a late note, but they have the option to do a MAR progress note. She stated if medications were given late, they were supposed to notify the charge nurse. She said the day shift [6am to 6pm] med aides were responsible for giving 6 pm medications before their shift ends. During an interview on 9/24/2025 at 3:56 pm, the DON stated staff can administer medications and hour before or an hour after the time in the EMR. If a medication is given late or missed, the med aides should notify the charge nurse. The charge nurse can evaluate the situation and consult with the practitioner as needed. She stated the med aide already there on day shift [6am - 6pm] was responsible for giving 6 pm medications. The DON stated their policy does not state the one-hour window before or after the time, but that was the procedure they followed. She stated this included an hour before or after for a specific time, as well as an hour before or after for a block of range of time. During another interview on 9/25/2025 at 12:03 pm, MA- A stated the medications for Resident #1 on 8/20/2025 and Resident #2 on 8/28/25 were late because these residents were her last two residents to give medications to and she just got to them late. She stated she did not recall if she informed the charge nurse, they were late and does not recall if she put in any MAR notes. She stated a concern for late administration of Carbidopa-Levodopa would be an increase in tremors or shaking but she did not remember seeing any symptoms when she was giving the meds late. During an interview on 9/25/2025 at 12:09 pm, MA-B stated they have an hour before and an hour after the stated time in the EMAR to administer medications to residents and any late or missed medication they were supposed to notify the charge nurse. She stated the administration time for Resident #1's Carbidopa-Levodopa medication on 8/21/2025 fell outside the 1-hour window and she was the MA that administered the medication to Resident #1. She does not know why she administered it late stating maybe he was in the bathroom. She stated she did not remember if she had notified the charge nurse, they were late. She stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Carbidopa-Levodopa medication helps with shaking for the residents. During an interview on 9/25/2025 at 12:34 pm, MA-C stated the facility policy allowed them to give medications an hour before or an hour after the schedule time. She stated she was the MA working on 8/20/25 and gave Resident #3 her Carbidopa-Levodopa that was scheduled at 2:00 pm, late and missed giving the resident her 6:00 pm dose. She stated the 2:00 pm dose was late because she was probably working on the other hall and didn't get to it in time. MA-C did not remember why she didn't give the 6:00 pm dose - she was not sure about that med if it lit up or not indicating the medication could be given. She did not recall if she had mentioned it to the charge nurse or completed a MAR note in the EMR. She stated her concerns with a late or missed medication like that would be more hand shaking, more body movements because the medications was given for Parkinson's Disease. She did not recall if Resident #3 had an increase in symptoms. Calls to Nurse D to interview her about her late medication administration for Resident #3 were attempted on 9/25/2025 at 12:42pm, 1:10 pm and 1:51 pm. Messages were left at each attempt, but no calls were returned. During an interview on 9/25/2025 at 12:49 pm, the hospice Medical Director (HMD) stated his expectations when a facility was given medication orders for a resident is that 1) the medications would be given; 2) the staff would make sure the resident took the medications, and 3) the medication was given at the times ordered - it is an order not a suggestion. The HMD stated he doesn't have any grave concerns for the late administration of the Carbidopa-Levodopa for Resident #3, but it could have caused an increase in symptoms [tremors] and confusion. During an interview on 9/25/2025 at 2:42 pm, the DON stated her expectation on mediations for residents was that the order would be followed through. If the orders could not be followed, staff would notify the nurse who would notify the NP. She stated her concerns with late medications is that the residents could have fallen out of their therapeutic range, and this could have caused an exacerbation of symptoms of their disease process. During an interview on 9/25/2025 at 3:00 pm, the ADM stated his expectation was that medication orders were followed and any reason for meds given outside of that window that the staff would notify clinical minds. The ADM stated his concerns would have been that residents could be chasing symptoms or there could have been a breakthrough in the disease process, and it would be harder to get it in control. Depending on how late the medication was, it could also have been too much if the late dose is given too close to the next dose and the therapeutic level could be off. During an interview on 9/25/2025 at 4:08 pm, the NP stated her expectation on medications orders would be that the orders were carried out and if there were any questions, the facility would call her in case she wanted to do something different for that resident. She stated she was not aware of the late medication administrations for Resident #1, Resident #2 or Resident #3. She stated her expectation on the timing of medication of Carbidopa-Levodopa was that most residents are admitted on the medication and the facility will get as close as possible to the scheduled time. She stated some residents would get symptomatic and have an increase in tremors or shaking if they did not get it when scheduled. She stated she was not aware of any adverse reactions due to the late medications. Review of facility Medication Admin Audit Report dated 9/24/2025 reflected Resident #1, Resident #2 and Resident #3 had Carbidopa-Levodopa medications administered late as reflected above. Review of undated facility policy Medication Administration Policy and Procedure revealed: PurposeThe purpose of this procedure is to provide guidelines for the safe administration of medications.PolicyThe facility shall provide medications as ordered by the physician.Procedure:1. Medications shall be administered only upon the order of physicians, dentists, or podiatrists. Event ID: Facility ID: 455351 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 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 maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #5) out of 5 residents reviewed for infection control. The facility failed to clean up blood splatters on the floor of Resident #5's room after IV therapy.These failures placed residents at risk of transmission and/or spread of blood borne pathogens including infections or contagious diseases which could lead to infections and hospitalization.Findings included:Review of Resident #5's face sheet dated 9/25/2025 reflected resident was an [AGE] year-old female admitted on [DATE] with diagnoses: metabolic encephalopathy, hypertension (high blood pressure), atrial fibrillation (heart rhythm disorder), hypothyroidism (thyroid disorder), vitamin deficiency. Review of Resident #5's progress notes dated 9/22/2025 reflected .MD informed who ordered Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML q6hr x5 days, Mucinex Oral Tablet Extended Release 12 Hour 600 MG (Guaifenesin) x5 days, Sodium Chloride Intravenous Solution 0.9 % (Sodium Chloride) 100ml @ 75ml/hr and Cefepime HCl Solution 1 GM/50ML x7 days, IV inserted into L forearm x1 attempt w/ 22g cath. Review of Resident #5's orders reflected an order dated 9/23/2025: IV to left arm Monitoring: Observe and record signs and symptoms of infection every 8 hours: 0- dressing dry and intact. No signs of redness, swelling or tenderness. 1 - redness 2 - swelling 3- tenderness 4 - Other: document findings in notes and notify MD/NP if signs or symptoms of infection occur. During an observation on 9/24/2025 at 12:55 pm, Resident #5 was in her room with a FM present, and several areas of dark red/brown fluid splatters were noted on the floor about resident's bed area. During an interview on 9/24/2025 at 12:57 pm Resident #5 stated the spots on the floor were blood from the day before when they gave her an IV. She stated she had to be careful when moving around her room in her wheelchair, so she didn't track the blood everywhere. During an interview on 9/24/2025 at 1:00 pm, the FM stated she noticed the blood splatters on the floor when she came in to visit Resident #5 and asked resident about them. Resident informed her they came from her IV the day before. The FM stated she had concerns about the cleaning of Resident #5's room and the possibility of something being spread around with the blood on the floor. During an interview on 9/25/2025 at 2:14 pm, the Housekeeping Supervisor stated resident rooms were cleaned daily. She was never notified of the dried blood on Resident # 5's floor. She stated she would have concerns about blood borne pathogens and the resident falling or slipping on the liquid and it getting tracked around into other places. She said if it was not cleaned up, it would be an infection control issue and potential for the spread of germs. She stated her expectations about blood spills were: 1) clean it up right away and 2) let her or housekeeping staff know so they can go clean and disinfect the area. She stated they got an in-service on blood spills yesterday that everyone was responsible for cleaning up spills and notifying housekeeping. During an interview on 9/25/2025 at 2:42 pm, the DON stated it was her expectation that blood spills be cleaned up immediately at the time of the incident, or the second someone sees it, they clean it up and notify housekeeping. She stated her concerns would be the fluid could cause a slip, trip or fall hazard as well as an infection control concern with exposure to blood borne pathogens. She stated they completed in services yesterday with staff and informed them to clean it up immediately, report to the charge nurse so the nurse could notify housekeeping immediately. During an interview on 9/25/2025 at 3:00 pm, the ADM stated his expectations on blood spills was that it has to be cleaned up right away, it's a biohazard. He stated the clinical staff has been trained on how to clean up biohazards and this should have been cleaned up. The ADM stated his concerns were that someone could have been infected by it, a Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete resident, family or staff and it's a dignity issue and a blood pathogen. Review of the undated facility policy Blood/Body Fluids-cleaning up spills/splashes Policy and Procedure revealed: Purpose:All spills or splashes of blood or other body fluids will be cleaned up and the spill or splash area will bedecontaminated as soon as practical. Procedure:1. Surfaces and equipment contaminated with spills or splashes of blood or body fluids must be cleanedup and disinfected as soon as practical.2. All employees must wear gloves when cleaning up spills or splashes of blood or body fluids. (Note:Other protective equipment (e.g., gowns, masks, and goggles) may be necessary if splashing of bloodor body fluids into the eyes, nose, or mouth, or soiling of clothing is likely. Shoe coverings will benecessary if there are large amounts of blood on the floor.)3. After cleaning up spills or splashes of blood or body fluids, the contaminated area must be disinfectedwith one of the following:4. Chemical germicides that are approved for use as hospital disinfectants and are tuberculocidal whenused at recommended dilutions.5. Products registered by the Environmental Protection Agency (EPA) as being effective against HIV withan accepted HIV (AIDS) virus label; or6. A solution of 5.25% sodium hypochlorite (household bleach) diluted between 1:10 and 1:100 withwater.7. On small spill or splash areas and on skin surfaces, a 70% isopropyl alcohol pledge may be used todisinfect the area.8. Hands must be washed as soon as practical after an exposure to blood or body fluids.9. All residents' blood and body fluids should be considered potentially infectious.10. Any exposure to a resident's blood or body fluids should be reported to the infection controlcoordinator. Event ID: Facility ID: 455351 If continuation sheet Page 5 of 5