Health inspection·January 15, 2026

F 0689 Level of Harm - Actual harm Residents Affected - Few occurred several hours prior to its discovery based on the extent of swelling. She further reported that Resident #1 was diagnosed with a right femoral fracture requiring surgical intervention. The RP added that the resident had a prior left hip replacement following a fall in October 2025. She stated that facility staff were unable to provide a definitive explanation for the injury and expressed her belief that the fracture might have resulted from a stress injury during repositioning or care.During a telephone interview on 01/15/26 at 3:16 p.m., CNA G stated she provided care to Resident #1 on the afternoon shifts of 01/09/26, 01/10/26, and 01/11/26. She reported no swelling or pain on 01/09/26 and 01/10/26. However, on 01/11/26 at about 4:30pm, she observed the resident moaning and grimacing in severe pain, with significant swelling of the right leg. She stated she immediately reported these findings to LVN H. When the investigator asked her if she was aware Resident #1 had experienced pain on 01/08/26 when moving her right leg, she responded that she did not know about it.On 01/15/26 at 2:45 p.m., a voicemail message was left for LVN H requesting a return call; no response was received.Review of a progress note dated 01/11/26, authored by LVN H, documented that CNA G reported Resident #1 to be in severe pain with significant swelling of the right upper leg between the hip and knee. Assessment revealed marked edema, warmth, and pain with palpation and movement. Tylenol was administered immediately, and the resident was transferred to the emergency department, as per the physician's order. She stated RN D reported to her about the pain Resident #1 had in the afternoon and was under observation.During an interview on 01/15/26 at 12:05 p.m., RN D stated that she worked the day shifts on 01/09/26, 01/10/26, and 01/11/26 and was not aware of Resident #1's complaint of right leg pain on 01/08/26, as the information was not communicated. She stated no pain complaints were reported on 01/09/26 or 01/10/26 though she had not assessed for pain specifically on her right leg. However, on 01/11/26 at approximately 4:30 p.m., CNA E reported that Resident #1 was shivering. Upon assessment, RN D observed signs of pain in the right leg, but no swelling or deformity observed. She administered Tylenol 650 mg as needed, after which the resident stopped shaking and exhibited no further signs of pain. RN D reported that she communicated this information to the oncoming nurse, LVN H, prior to the end of her shift at 6:00pm.During an interview on 01/15/26 at 3:01 p.m., CNA E stated that she worked with Resident #1 on the afternoon shift of 01/08/26 and observed no swelling or pain during incontinence care. She stated that she worked at the facility on 01/10/26 and 01/11/26, however she had not worked with Resident #1 on 01/09/26 or 01/10/26. On 01/11/26, she observed Resident #1 shivering in pain during lunch, while serving lunch to the residents and reported it to RN D. She said later that day she came to know that the resident had been noted to have pain on 01/08/26 through somebody else (unable to remember who that was).During a telephone interview on 01/15/26 at 1:55 p.m., CNA B stated that while working the day shift on 01/08/26, Resident #1 exhibited pain when her right leg was moved during incontinence care. CNA B reported that although the resident was sometimes combative, on that day she was quiet. CNA B stated she informed LVN A of the change in condition; LVN A assessed the resident and administered pain medication. CNA B further stated that later the resident was observed in common areas in her wheelchair without apparent signs of pain or discomfort. CNA B stated she worked again on 01/09/26 and reported being cautious when providing care for the right leg, noting no further signs of pain. She did not work on 01/10/26 or 01/11/26.During a telephone interview on 01/15/26 at 2:05 p.m., LVN A reported that on the morning of 01/08/26, CNA B informed her that Resident #1 complained of pain from her right leg during perineal care. LVN A stated she completed an assessment and noted no abnormalities, deformities, swelling, or redness of the bilateral lower extremities. However, when perineal care was attempted again, the resident moaned when her right leg was grasped. She stated Resident #1 did not have the cognitive ability to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 2 of 4 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 01/15/2026 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 0689 Level of Harm - Actual harm Residents Affected - Few express her pain verbally. LVN A stated she specifically assessed the right leg again and found no visible abnormalities. She administered Acetaminophen (Tylenol)325 mg, two tablets, as needed for pain, and the resident did not complain of pain for the remainder of the day. LVN A stated she was not sure if she had communicated about the incident to the incoming nurse, LVN C, during the shift change. She said she did not report the issue to the NP and forgot to document the incident in the EHR. She stated she should have documented the incident as well as report it to NP and LVN C to ensure monitoring and continuity of care.During an interview on 01/15/26 at 2:17 p.m., LVN C stated that he worked the night shift on 01/08/26 and was not informed of Resident #1's complaint of right leg pain during the change of shift by LVN A. He indicated that he did not perform a focused assessment of the right leg during his shift as he was not aware of the issue with Resident #1's right leg.During an interview on 01/15/26 at 2:30 p.m., CNA I stated that she worked the morning shifts on 01/10/26 and 01/11/26 (6:00 a.m. to 2:00 p.m.). She stated she was not aware of the pain from the right leg of Resident #1 with movements and did not find any signs of pain, swelling, or redness in Resident #1's lower extremities while changing her briefs. Resident #1 was combative sometimes and had not checked for any sign of pain while changing her briefs on these days. She stated if she was aware of the concern with her right leg, she would have observed the resident closely for pain with the movements of the affected leg.During an interview on 01/15/26 at 4:15 p.m., the NP stated she received a call on 01/11/26 regarding swelling and pain in Resident #1's right leg and ordered transfer to the emergency department. She reported she was not aware of the pain episode on 01/08/26. The NP stated the resident had a history of left hip fracture and was prescribed Tylenol as needed, with order for pain assessment each shift. She identified severe pain, swelling, deformity, and redness as possible indicators of fracture and stated she could not determine the exact timeframe for the onset of swelling following a fracture. The NP stated she was not sure if the complaint of pain in the right leg of Resident #1 on 01/08/26 was related to the fracture as there was no swelling or deformity observed at that time. She stated that, considering the age and condition of Resident #1, the finding on 01/08/26 should have been communicated with her and continue to assess and monitor Resident #1 for the pain and change of condition originating on the affected leg.During an interview on 01/15/26 at 10:30 a.m., the DON stated that Resident #1 returned from the hospital on [DATE] following surgical repair of the right femur fracture after being admitted to hospital with swelling on her right leg and pain. The DON reported that on 01/08/26 at approximately 9:00 a.m., CNA B noted the resident moaning and grimacing in pain when her right leg was moved and reported this to LVN A, who assessed the resident and administered Tylenol. The DON stated it was unclear whether this information was communicated to subsequent shifts, however there were no reports of pain or swelling until 01/11/26. She stated there was no information available if Resident #1 was assessed for pain from her right leg. Upon review of the incident, the DON said there was no evidence of follow-up assessment or communication regarding Resident #1's pain until the evening of 01/11/26. The DON stated that the exact timing of the fracture could not be determined. She stated Resident #1 had no fall episodes in the month of January 2026. She indicated that although pain was noted with movement of the right leg on 01/08/26, there were no visible signs of fracture at that time. She stated staff should have conducted focused pain assessments and observations for change of condition of the affected extremity. She further stated that there was no documentation of continued assessment or observation following the initial complaint on 01/08/26. However, she noted that interviews with CNAs who worked on 01/09/26 and 01/10/26 revealed no observed signs of pain or swelling during care across shifts. Record review of the facility's undated policy ‘Abuse prevention and prohibition reflected: . Injuries of Unknown Origin: An (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 3 of 4 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 01/15/2026 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 0689 Level of Harm - Actual harm injury should be classified as injury of unknown origin whenBoth of the following criteria are met: The source of the injury was not observed by any person, or the source of injury could not be explained by the resident.A licensed professional nurse will examine the resident for signs of injury and notify the resident'sphysician of any injuries noted. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455351 If continuation sheet Page 4 of 4