Health inspection·December 1, 2025

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete went off and she immediately brought the resident back in. In an interview on 11/12/25 at 10:55 AM, the DON said in April 2025 Resident #1 was visualized going out the door at the end of the hall by ADON A but the staff could not get to her before she went out the door. She send ADON A was alerted to Resident #1 going out the door by an audible alarm, and then immediately returned the resident inside the facility. The DON said Resident #1 was in a wheelchair and she propelled herself around the building, was combative and resistant to care. She said the MDS represented the resident and the care they should receive. The DON said an inaccurate MDS could potentially impact how the resident is cared for. In an interview on 11/12/25 at 11:30 AM, the MDS Nurse said she was new and did not complete Resident #1's assessments. She said the MDS is completed with information from the IDT as well as interviews and observations with family and the resident. She said from what she heard, Resident #1 had behaviors of resisting care but her MDS was codded as no behaviors. The DON said Resident #1 had behaviors since she admitted to the facility in 2024. She said the resident was not friendly, had behaviors most of the time, would grab staff, had verbal behavioral symptoms, roamed in her wheelchair, wandered around and rejected care 4-6 times a week. After the DON reviewed Resident #1's MDS from 10/03/25 and 10/28/25 she said they were inaccurate because they did not acknowledge Resident #1's physical, verbal and other behavioral symptoms. An observation on 11/12/25 at 11:54 AM revealed, Resident #1 sitting in her wheelchair in the doorway of her room receiving Vancomycin 750 mg/ml in 750 ml IV at 250 ml/hr. Her left foot was wrapped in a white dressing and her right arm had IV tubing protruding from under a white gauze dressing. The IV bag had no labeling outside of the manufacturer labeling, there was no pharmacy label that contained the resident's name, dose and instruction for use, administration flow rate, name of prescriber, or date the medication was ordered. Observation revealed a dial a flow pump. The resident was not interviewable, she was confused, tugged on her IV tubing and was combative with staff who passed by. In an interview on 11/12/25 at 11:58 AM, RN A said Resident #1 was confused and was not interviewable. She said the resident was combative and resistant to care, she would not let anyone touch her or provide care. Record review of the facility policy titled Resident Assessment and Associated Processes revised 04/2025 revealed, It is the policy of this facility that resident will be assessed and the findings documented in their clinical health record. These will be comprehensive, accurate, standardized reproducible assessment of each resident and will be conducted initially and periodically as part of an ongoing process through which each resident's preferences and goals of care, functional and health status, and strengths and needs will be identified. An accurate Comprehensive Assessment will be made of the resident's needs, strengths, goals, life history and preferences, using the RAI (Resident Assessment Instrument) and will include at least the following: Identification and demographic information; Customary routine; Cognitive patterns; Communication, Vision; Mood and behavior patterns; Psychological well-being. 5. Assessment information will be used to develop, review, and revise the resident's comprehensive care plan. 7. Each individual who completes a portion of the assessment will electronically sign and certify the accuracy of that portion of the assessment, as well as the date the data was obtained. Event ID: Facility ID: 676137 If continuation sheet Page 2 of 18 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 676137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 8902 West Rd Houston, TX 77064 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 0694 Provide for the safe, appropriate administration of IV fluids 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 administer Parenteral fluids consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 (Resident #1) residents reviewed for parenteral fluids. - RN A failed to administer Resident #1's IV antibiotic Vancomycin, a medication with known infusion rate reactions, as ordered when she administered the medication at 250 ml/hr. instead of 150 ml/hr. as ordered on by the pharmacy on 11/12/25. This failure could place residents at vancomycin infusion reactions which could result in hypotension (low blood pressure), tachycardia (fast heartrate) and cardiac arrest (when the heart suddenly stops beating). Findings includeRecord review of Resident #1's Face Sheet dated 11/12/25 revealed, a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: COPD (group of lung diseases that block airflow cause difficulty breathing), muscle weakness, depression, difficulty walking, right great toe amputation, lower left leg open wound and peritoneal abscess (pus within the abdomen due to an infection).Record review of Resident #1's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, fluctuating behaviors of: inattention, disorganized thinking and altered level of consciousness. Behavioral symptoms of: physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing), Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, , or verbal/vocal symptoms like screaming, disruptive sounds) were marked as Behavior not exhibited. Rejection or care and wandering were marked as: Behavior not exhibited.Record review of Resident #1's undated Care Plan revealed, focus: COPD (Chronic Obstructive Pulmonary Disease) r/t SOB, use of medications. Focus: Is on IV Vancomycin HCl Intravenous Solution Reconstituted 750 MG (Vancomycin HCl) r/t leukocytosis (elevated white blood cell count indicating infection). Goal: Will not have any complications related to IV Therapy through the review date. Focus created on 09/16/24 and revised on 09/29/25: [Resident #1][ exhibits Behaviors r/t Elopement risk/wanderer, disoriented to place, wanders aimlessly, refuses ADL care/showers frequently. Yells out at other residents. Removes her wound bandages, removes her colostomy bag.Record review of Resident #1's Oder Summary Report dated 11/12/25 revealed, Vancomycin HCl Intravenous Solution Reconstituted 750 MG (Vancomycin HCl) Use 750 mg intravenously every 12 hours for abnormal lab for 10 Days; start date 11/11/25.Record review of Resident #1's November 2025 MAR revealed, the first dose of Vancomycin Resident #1 received was administered by RN A on 11/12/25 at 11:21 AM.Record review of Resident #1's Change in Condition assessment dated [DATE] revealed, staff monitored for adverse reactions due to Vancomycin and Resident #1 did not have any changes/remained stable. Her vitals were within range, she had normal body temperature (97.7), blood pressure (118/62), Respirations (17), pulse (72) and her oxygen rate was at 97 %. The nurse received orders for an immediate test of Resident #1's Vancomycin Levels and a BMP.Record review of Resident #1's Progress Notes dated 11/12/25 at 12:35 PM signed by ADON A revealed, Resident assessed for [adverse reactions] to Vancomycin IV. Medical Director in building and updated on Vancomycin administration issue. MDinformed no adverse reaction noted during assessment. New orders received from medical director after viewing resident for STAT Trough (immediate laboratory values) ordered to ensure resident is in therapeutic range with medication. BMP to be drawn tomorrow and redraw for Vanco trough 11/14. Vancomycin to be held until result is received for STAT trough and observed resident q 1hr x 24 hours. NP called and updated on the above.Record review of Resident #1's Lab results dated 11/13/25 revealed, the vancomycin levels came out as low Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676137 If continuation sheet Page 3 of 18 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 676137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 8902 West Rd Houston, TX 77064 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and there were no significant change to her BMP.An observation on 11/12/25 at 11:52 AM revealed, Resident #1 in her wheelchair in the doorway of her room as she received Vancomycin 750 mg/150 ml at 250 ml/hr. (calculated administration duration of 36 minutes). Her left foot was wrapped in a white dressing and her right arm had IV tubing that protruded from under a white gauze dressing. The IV bag had no labeling outside of the manufacturer labeling, there was no pharmacy label that contained the resident's name, dose and instruction for use, administration flow rate, name of prescriber, or date the medication was ordered. The resident was not interviewable, she was confused, tugged on her IV tubing and was combative with staff who passed by. Resident #1 appeared to be in no immediate distress, her skin was not red, she took normal breaths and had no shortness of breath.In an interview on 11/12/25 at 11:54 AM, RN A said the label for Resident #1's Vancomycin must have fallen off after she hung the medication and all medications must have a pharmacy label that includes the residents name, medication information and directions for use. She went to get a new label and when she returned she informed the surveyor the pharmacy label instructed the vancomycin be administered at 750 mg at 150 ml/hr. every 12 hours and she started the infusion at approximately 11:30 AM. RN A said if Vancomycin was administered rapidly a resident could suffer from burning from the IV, she was not aware of any Vancomycin specific infusion reactions.In an observation and interview that started at 11/12/25 at 11:59 AM, the DON said Vancomycin must be administered at the ordered rate because rapid infusion of Vancomycin can result in red man syndrome which could result in flushing (redness), hypotension and cardiac arrest. The surveyor notified the DON of Resident #1's Vancomycin being administered at 250 ml/hr. instead of 150 ml/hr. The DON immediately located Resident #1 in the dining room (the IV was set at 150 ml/hr. when the resident was found in the dining room), returned her to her bedroom and began assessing the resident. The IV was stopped at 12:07 PM, then the DON checked Resident's upper torso for redness and hives to which there was none and Resident #1 began to question what the DON was doing and resist the assessment. Resident #1 appeared to be in no immediate distress, her breathing was normal, she had no redness.In an interview on 11/12/25 at 12:20 PM, the Medical Director said residents that received Vancomycin rapidly could suffer from Red Man Syndrome which is a Vancomycin infusion reaction that can result in tinnitus (ringing/buzzing or hissing in the ear caused by no external source), changes in vitals like hypotension, tachycardia, chest pain, shortness in breath caused by angioedema (swelling in the skin affecting the face, lips, tongue and throat). He said if a resident received Vancomycin at a rate higher than ordered, he expected the IV to be stopped immediately, the resident assessed and the provider notified immediately for orders. He said Vancomycin administered at an incorrect rate was considered a significant medication error but Resident #1 was assessed and suffered no harm. The resident was stable, and labs were ordered to check her Vancomycin level.In an interview on 11/12/25 at 12:28 PM, the DON said Resident #1 was assessed and she had no SOB, Discomfort, irritation at IV site, no pain and her vitals were within normal limits. She said when IV medication was administered nursing staff reviewed the order, retrieved supplies, notified the resident of the medication being administered, performed hand hygiene, donned the appropriate PPE, flushed the line and connected the IV medication following proper infection prevention techniques. The DON said the flow rate was determined by the orders on the bag and failure to administer IVs as ordered could result in adverse drug reactions. She said a significant med error was when an error made could be critical, and caused a significant change in a residents condition. The DON said when a resident experienced a significant medication error, the medication should be stopped immediately, the resident must be immediately assessed and the provider notified.In an observation and interview in the medication room on 11/12/25 at 12:43 PM, the DON said all IV medications should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676137 If continuation sheet Page 4 of 18 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 676137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 8902 West Rd Houston, TX 77064 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few have a pharmacy label that included the pharmacy's information, resident's name, medication information and directions for use. A bag of Resident #1's IV Vancomycin was observed in the fridge with each IV bag wrapped in a foil manufacturer bag and an attached pharmacy label with pharmacy information, resident information, provider information, drug information and directions for use. The label read Vancomycin 750 ml: Infuse intravenously 150 ml (750 mg) over 60 minutes every 12 hours for 10 days. In an interview on 11/12/25 at 02:16 PM, RN A said she knew Resident #1's Vancomycin was ordered at 150 ml/hr. and she intentionally administered the medication against physician's orders at 250 ml/hr. She said she did not notify members of nursing management when she changed the administration rate. RN A said when she checked the medication room there was no medication pump she could use and since Resident #1 was so combative she wanted to ensure Resident #1 received the antibiotic because nothing else had worked. RN A said she was not aware residents could suffer from an infusion reaction but now she was aware.In an interview on 11/12/25 at 02:40 PM, ADON B said between 9:00 and 10:00 AM RN A asked her if IV vancomycin had to be administered using a medication pump. She said yes and when RN A checked the facility there was no pump available so she instructed RN A to not administer the medication and wait for pharmacy to deliver the pump. ADON B said Vancomycin had to be administered by a pump due to its toxicity/narrow therapeutic window because the pump ensured the resident received the right dose for safety reasons.In an interview on 11/12/25 at 02:53 PM, the NP said when she prescribed vancomycin the pharmacy calculated the rate of administration and nursing staff were expected to administer the medication per the pharmacy orders. She said when Vancomycin was administered rapidly, residents could suffer from VIR (vancomycin infusion reactions) which caused rash, hypotension and tachycardia. She said RN A's failure to administer Vancomycin as ordered was a safety concern because her role as a nurse was to follow orders as written.In an interview on 11/12/25 at 03:30 PM, the Pharmacist said the administration rate of Resident #1's Vancomycin was determined by the manufacturers recommendation to be administered over 1 hour and she was ordered to receive the 750 mg dose in the 150 ml solution at 150 ml/hr. He said if Vancomycin was administered too fast a resident could suffer from a pretty bad reaction and they could experience hypotension, tachycardia and cardiac arrest. The pharmacist said nursing staff are expected to follow the pharmacy ordered rate and it was labeled pretty clearly. He said even though RN A did not administer the medication as ordered it was a low risk for an adverse reaction.Record review of the facility policy titled Administration of Drugs and Fluids, Intravenous revised 05/2021 revealed, POLICY:It is the policy of this facility that medications shall be administered as prescribed by the attending physician. PROCEDURES: 1. Only licensed medical and nursing personnel or other lawfully authorized staff members may prepare, administer, and record the administration of medications. 2. Medications must be administered in accordance with the written orders of the attending physician. 8. Verify that the container's label coincides with the prescriber's order. Verify content, dose, prescribed rate, and expiration date of the solution. The seven rights of medication administration are as follows in order to ensure safety and accuracy of administration. 1. Right Resident - Resident is identified prior to medication administration; 2. Right Time - Medications are administered within prescribed time frames. 3. Right Medication - Medications are checked against the order before they are given. 4. Right Dose - Medications are administered according to the dose prescribed Record review of the manufacturer's Highlights of Prescribing Information revised 05/2021 revealed, Infusion Reactions: Hypotension, including shock and cardiac arrest, wheezing, dyspnea (shortness of breath), urticaria (hives), muscular and chest pain and red man syndrome which manifests as pruritus (itching) and erythema (redness) that involves the face, neck and upper torso may occur with rapid intravenous administration. To reduce the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676137 If continuation sheet Page 5 of 18 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 676137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 8902 West Rd Houston, TX 77064 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete risk of infusion reactions, administer Vancomycin Injection over a period of 60 minutes or greater and also prior to intravenous anesthetic agent. ADVERSE REACTIONS: The common adverse reactions are anaphylaxis, red man syndrome, acute kidney injury, hearing loss, neutropenia (low type of white blood cell). Record review of the facility policy Administering Medications revised 05/18/2023 revealed, Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. 3. Medications must be administered in accordance with the orders, including any required time frame. 6. The individual administering the medication must check the label to verify the right medication, right dosage, right time and right method (route) of administration before giving the medication. 20. New personnel authorized to administer medications will not be permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility. Event ID: Facility ID: 676137 If continuation sheet Page 6 of 18 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 676137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 8902 West Rd Houston, TX 77064 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure nurses were able to demonstrate competency in skills to provide nursing and related services for 1 of 1 resident (Resident #1) by 1 of 4 nurses (RN A) reviewed for competent staff. - The facility failed to ensure RN A was competent to administer medications via IV prior to administering medications to Resident #1 on 11/12/25 This failure could place residents at complications from IV medications and adverse reactions. Findings included: Record review of Resident #1's Face Sheet dated 11/12/25 revealed, a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: COPD (group of lung diseases that block airflow cause difficulty breathing), muscle weakness, depression, difficulty walking, right great toe amputation, lower left leg open wound and peritoneal abscess (pus within the abdomen due to an infection). Record review of Resident #1's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, fluctuating behaviors of: inattention, disorganized thinking and altered level of consciousness. Behavioral symptoms of: physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing), Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, , or verbal/vocal symptoms like screaming, disruptive sounds) were marked as Behavior not exhibited. Rejection or care and wandering were marked as: Behavior not exhibited. Record review of Resident #1's undated Care Plan revealed, focus: COPD (Chronic Obstructive Pulmonary Disease) r/t SOB, use of medications. Focus: Is on IV Vancomycin HCl Intravenous Solution Reconstituted 750 MG (Vancomycin HCl) r/t leukocytosis (elevated white blood cell count indicating infection). Goal: Will not have any complications related to IV Therapy through the review date. Focus created on 09/16/24 and revised on 09/29/25: [Resident #1] exhibits Behaviors r/t Elopement risk/wanderer, disoriented to place, wanders aimlessly, refuses ADL care/showers frequently. Yells out at other residents. Removes her wound bandages, removes her colostomy bag. Record review of Resident #1's Oder Summary Report dated 11/12/25 revealed, Vancomycin HCl Intravenous Solution Reconstituted 750 MG (Vancomycin HCl) Use 750 mg intravenously every 12 hours for abnormal lab for 10 Days; start date 11/11/25. Record review of Resident #1's November 2025 MAR revealed, the first dose of Vancomycin Resident #1 received was administered by RN A on 11/12/25 at 11:21 AM. An observation on 11/12/25 at 11:52 AM revealed, Resident #1 in her wheelchair in the doorway of her room as she received Vancomycin 750 mg/150 ml at 250 ml/hr. (calculated administration duration of 36 minutes). Her left foot was wrapped in a white dressing and her right arm had IV tubing that protruded from under a white gauze dressing. The IV bag had no labeling outside of the manufacturer labeling, there was no pharmacy label that contained the resident's name, dose and instruction for use, administration flow rate, name of prescriber, or date the medication was ordered. The resident was not interviewable, she was confused, tugged on her IV tubing and was combative with staff who passed by. Observation revealed a dial a flow pump. Resident #1 appeared to be in no immediate distress, her skin was not red, she took normal breaths and had no shortness of breath. In an interview on 11/12/25 at 11:54 AM, RN A said the label for Resident #1's Vancomycin must have fallen off after she hung the medication and all medications must have a pharmacy label that includes the residents name, medication information and directions for use. She went to get a new label and when she returned she informed the surveyor the pharmacy label ordered the vancomycin be administered at 750 mg at 150 ml/hr. every 12 hours and she started the infusion at approximately 11:30 AM. RN A said if Vancomycin was administered rapidly a resident could suffer from burning from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676137 If continuation sheet Page 7 of 18 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 676137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 8902 West Rd Houston, TX 77064 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the IV, she was not aware of any Vancomycin specific infusion reactions. In an observation and interview that started at 11/12/25 at 11:59 AM, the DON said Vancomycin must be administered at the ordered rate because rapid infusion of Vancomycin can result in red man syndrome which could result in flushing (redness), hypotension and cardiac arrest. In an interview on 11/12/25 at 12:05 PM, ADON A said to her knowledge RN A intentionally changed the medication flow rate to 250 ml/hr. because it was going to slow. ADON A said RN A said she was told by ADON B not to administer the medication until the pump arrived but RN A did not want a delay in Resident #1 receiving her antibiotic due to the absence of an IV pump. In an interview on 11/12/25 at 12:20 PM, the Medical Director said residents who received Vancomycin intravenously could suffer from Red Man Syndrome which is a Vancomycin infusion reaction that can result in tinnitus (ringing/buzzing or hissing in the ear caused by no external source), changes in vitals like hypotension, tachycardia, chest pain, shortness in breath caused by angioedema (swelling in the skin affecting the face, lips, tongue and throat). In an interview on 11/12/25 at 12:28 PM, the DON said when IV medication was administered nursing staff reviewed the order, retrieved supplies, notified the resident of the medication being administered, performed hand hygiene, donned the appropriate PPE, flushed the line and connected the IV medication following proper infection prevention techniques. The DON said the flow rate was determined by the orders on the bag and failure to administer IVs as ordered could result in adverse drug reactions. She said a significant med error was when an error made could be critical, and caused a significant change in a residents condition. The DON said when a resident experienced a significant medication error, the medication should be stopped immediately, the resident must be immediately assessed and the provider notified. In an observation and interview in the medication room on 11/12/25 at 12:43 PM, the DON said all IV medications should have a pharmacy label that included the pharmacy's information, resident's name, medication information and directions for use. A bag of Resident #1's IV Vancomycin was observed in the fridge with each IV bag wrapped in a foil manufacturer bag and an attached pharmacy label with pharmacy information, resident information, provider information, drug information and directions for use. The label read Vancomycin 750 ml: Infuse intravenously 150 ml (750 mg) over 60 minutes every 12 hours for 10 days. The DON said failure to label medication could result in staff being unaware of the instructions for use including the dosing. In an interview on 11/12/25 at 01:11 PM, RN A said she started working in the facility in 10/2025. She said before medication was administered via IV, staff verified the order, retrieved the medication from the med room, assessed the resident, flushed the line, connected the IV, and then set the flow rate per the instructions on the IV label. RN A said the facility had two methods of administering IVs, an IV pump which came from the pharmacy or Dial-a-flow tubing which had a dial on the tubing to set the administration rate. She said nursing staff are expected to double check the flow rate prior to starting the infusion and then monitored the resident for at least 15 minutes after the infusion started to ensure the resident did not suffer from an adverse drug reaction. RN A said, a significant med error was this one (Resident #1's vancomycin administration outside of pharmacy orders) and she had not received any training on significant medication errors prior to starting her position on the flow. She said when a resident suffered from a significant medication error they stopped the medication immediately, assessed the resident, reported the error to the DON/NP, and awaited instructions. She said she was not educated about the specific infusion reactions that could occur with Vancomycin infusion rates and after the surveyor notified her of the wrong rate Resident #1 received her Vancomycin, she immediately changed the flow rate to 150 ml/hr. but she did not assess the resident. RN A said she did not follow the appropriate procedures for a significant medication error because she did not stop the infusion, Resident #1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676137 If continuation sheet Page 8 of 18 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 676137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 8902 West Rd Houston, TX 77064 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was not assessed, but instead the rate was lowered and the resident was moved to the dining room with no observations completed. She said she was not trained and did not know what assessments had to be completed for vancomycin infusion reactions, she had not received training on how to use dial-a-flow tubing and she had not receiving any training on IV medication administration. RN A said no one had completed a skills assessment of her administration of IV medications and prior to working at the facility she was a nurse that worked from home. She said Resident #1 was her first experience with the dial-a-flow tubing. In an interview on 11/12/25 at 01:36 PM, the DON said seasoned nurses received 3 days of training before they were allowed on the floor and then trained continuous while employed as needed. She said all nurses should have competency assessments completed prior to working independently on the floor. The DON said the facility did not have a system in place to double check IV administration as it relied on the competency of the nurse administering the medication. She said the nurse must follow the rights of medication administration and double check the administration rate of IV medications because a second nurse does not check behind them. The DON said nurses that are not IV certified, like LVNs, received IV training before performing this tasks, but all RNs are IV certified. She said the facility had a skills fair IV training annually in February or March but there was no specific training about using the dial-a-flow tubing. The DON said she did not have any records to indicate RN A received any specific training on the use of dial-a-flow tubing or IV medication administration. She said RN A had no training on Vancomycin infusions or Vancomycin infusion reactions because that competency was expected with each nurses professional license. In an interview on 11/12/25 at 02:16 PM, RN A said she knew Resident #1's Vancomycin was ordered at 150 ml/hr. and she intentionally administered the medication against physician's orders at 250 ml/hr. She said she did not notify members of nursing management when she changed the administration rate. RN A said when she checked the medication room there was no medication pump she could use and she was not aware residents could suffer from an infusion reaction but now she was aware. RN A said ADON B instructed her not to administer the medication and to wait for the pharmacy to deliver the IV pump but since Resident #1 was so combative she wanted to ensure Resident #1 received the antibiotic because nothing else had worked for her infection. She said she was not aware that Vancomycin administered rapidly could result in an infusion reaction. In an interview on 11/12/25 at 02:40 PM, ADON B said between 9:00 and 10:00 AM RN A asked her if IV vancomycin had to be administered using a medication pump. She said yes and when RN A checked the facility there was no pump available so she instructed RN A to not administer the medication and wait for pharmacy to deliver the pump. ADON B said Vancomycin had to be administered by a pump due to its toxicity/narrow therapeutic window because the pump ensured the resident received the right dose for safety reasons. Record review of RN A's Medication Administration- Skills Checklist signed 09/23/25 revealed, Medication Administration- Skills checklist requirement Met was checked. There was no competency for IV medication administration or dial-a-flow tubing competencies documented on the checklist. Record review of the facility policy titled Administration of Drugs and Fluids, Intravenous revised 05/2021 revealed, POLICY:It is the policy of this facility that medications shall be administered as prescribed by the attending physician. PROCEDURES:1. Only licensed medical and nursing personnel or other lawfully authorized staff members may prepare, administer, and record the administration of medications. 2. Medications must be administered in accordance with the written orders of the attending physician. 8. Verify that the container's label coincides with the prescriber's order. Verify content, dose, prescribed rate, and expiration date of the solution. The seven rights of medication administration are as follows in order to ensure safety and accuracy of administration. 1. Right Resident - Resident is identified prior to medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676137 If continuation sheet Page 9 of 18 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 676137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 8902 West Rd Houston, TX 77064 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete administration; 2. Right Time - Medications are administered within prescribed time frames. 3. Right Medication - Medications are checked against the order before they are given. 4. Right Dose - Medications are administered according to the dose prescribed Record review of the manufacturer's Highlights of Prescribing Information revised 05/2021 revealed, Infusion Reactions: Hypotension, including shock and cardiac arrest, wheezing, dyspnea (shortness of breath), urticaria (hives), muscular and chest pain and red man syndrome which manifests as pruritus (itching) and erythema (redness) that involves the face, neck and upper torso may occur with rapid intravenous administration. To reduce the risk of infusion reactions, administer Vancomycin Injection over a period of 60 minutes or greater and also prior to intravenous anesthetic agent. ADVERSE REACTIONS: The common adverse reactions are anaphylaxis, red man syndrome, acute kidney injury, hearing loss, neutropenia (low type of white blood cell). Record review of the facility policy Administering Medications revised 05/18/2023 revealed, Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. 3. Medications must be administered in accordance with the orders, including any required time frame. 6. The individual administering the medication must check the label to verify the right medication, right dosage, right time and right method (route) of administration before giving the medication. 20. New personnel authorized to administer medications will not be permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility. Record review of the facility policy titled Nursing Staff Competency revised 04/2025 revealed, Policy: It is the policy of this facility to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required. Procedure: 2. Within 30 days of the date of hire, the nursing staff member shall complete the orientation competency assessment for the appropriate job category to meet the needs of the facility's resident population in accordance with the facility assessment. a. Competency in skills and techniques to care for residents' needs may include but are not limited to: Medication management Event ID: Facility ID: 676137 If continuation sheet Page 10 of 18 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 676137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 8902 West Rd Houston, TX 77064 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 1 of 1 facility reviewed for required postings. - On 11/12/25 the facility failed to ensure the Direct Care Daily Staffing Numbers were updated. The postings read 11/11/25. This failure could affect residents, facility visitors, vendors, and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings Included: An observation on 11/12/25 at 08:51 AM revealed, the facility Direct Care Daily Staffing Numbers displayed on the pony wall on the left side of the front entrance. The posting read Date: 11-Nov-2025' and included the facility name, census, the scheduled hours, and staffing totals for direct care staff. RNs, LVNs and some CNAs worked 12 hour shifts from 6:00 AM to 6:00 PM or 6:00 PM to 6:00 AM. Nursing Managers and the DON worked from 9:00 AM to 5:00 PM, CNAs: 10:00 PM to 6:00 AM, CMAs 6:00 AM - 2:00 PM and 2:00 PM to 10:00 PM. An observation on 11/12/25 at 08:51 AM revealed, the facility Direct Care Daily Staffing Numbers displayed on the wall by the DON's office. The posting read Date: 11-Nov-2025' and included the facility name, census, the scheduled hours, and staffing totals for direct care staff. RNs, LVNs and some CNAs worked 12 hour shifts from 6:00 AM to 6:00 PM or 6:00 PM to 6:00 AM. Nursing Managers and the DON worked from 9:00 AM to 5:00 PM, CNAs: 10:00 PM to 6:00 AM, CMAs 6:00 AM - 2:00 PM and 2:00 PM to 10:00 PM. An observation on 11/12/25 at 09:08 AM revealed, the Staffing Coordinator as she removed the old direct care posting from the wall by the DONs office. In an interview on 11/12/25 at 10:38 AM, the Administrator said the Staffing Coordinator was responsible for the direct care posting. He said the posting should be posted somewhere visible within 2 hours of the first shift. He said the facility had 12 hour shifts for nurse and CNAs from 6- 6 and the posting should be up by 8:00 AM and before each shift. The Administrator said failure to update the posting timely could cause family members confusion of who was giving care that day. In an interview on 11/12/25 at 11:16 AM, the Staffing Coordinator said she made the schedules for the nursing department, found staffing, worked as a CNA/MA as needed and she was responsible for the daily direct care posting. She said the direct care posting had to be posted within 2 hours of the shifts, the facility shifts were 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM and must include the facility name, date, census, staffing types scheduled and the total number of scheduled staff. She said failure to update the posting timely could result in residents and visitors to the building not knowing the facility census or the staffing available for the day. The Staffing Coordinator said her shifts typically ran from 08:15 AM to 05:15 PM and she was expected to update the posting within 2 hours of the beginning of her shift. She said she had not received any training about the regulations regarding the timing of the posting. The Staffing Coordinator said when she arrived on 11/12/25 she was helping residents on the floor which caused her update of the posting to be delayed. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676137 If continuation sheet Page 11 of 18 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 676137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 8902 West Rd Houston, TX 77064 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 0760 Ensure that residents are free from significant medication errors. 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 residents were free from any significant medication errors for 1 of 4 residents (Residents #1) reviewed for significant medication errors. RN A failed to administer Resident #1's IV antibiotic Vancomycin, a medication with known infusion rate reactions, as ordered when she intentionally administered the medication at 250 ml/hr. instead of 150 ml/hr. as ordered by the pharmacy. This failure could place residents at vancomycin infusion reactions which could result in hypotension (low blood pressure), tachycardia (fast heartrate) and cardiac arrest (when the heart suddenly stops beating). Findings included Record review of Resident #1's Face Sheet dated 11/12/25 revealed, a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: COPD (group of lung diseases that block airflow cause difficulty breathing), muscle weakness, depression, difficulty walking, right great toe amputation, lower left leg open wound and peritoneal abscess (pus within the abdomen due to an infection). Record review of Resident #1's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, fluctuating behaviors of: inattention, disorganized thinking and altered level of consciousness. Behavioral symptoms of: physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing), Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, , or verbal/vocal symptoms like screaming, disruptive sounds) were marked as Behavior not exhibited. Rejection or care and wandering were marked as: Behavior not exhibited. Record review of Resident #1's undated Care Plan revealed, focus: COPD (Chronic Obstructive Pulmonary Disease) r/t SOB, use of medications. Focus: Is on IV Vancomycin HCl Intravenous Solution Reconstituted 750 MG (Vancomycin HCl) r/t leukocytosis (elevated white blood cell count indicating infection). Goal: Will not have any complications related to IV Therapy through the review date. Focus created on 09/16/24 and revised on 09/29/25: [Resident #1] exhibits Behaviors r/t Elopement risk/wanderer, disoriented to place, wanders aimlessly, refuses ADL care/showers frequently. Yells out at other residents. Removes her wound bandages, removes her colostomy bag. Record review of Resident #1's Oder Summary Report dated 11/12/25 revealed, Vancomycin HCl Intravenous Solution Reconstituted 750 MG (Vancomycin HCl) Use 750 mg intravenously every 12 hours for abnormal lab for 10 Days; start date 11/11/25. Record review of Resident #1's November 2025 MAR revealed, the first dose of Vancomycin Resident #1 received was administered by RN A on 11/12/25 at 11:21 AM. Record review of Resident #1's Change in Condition assessment dated [DATE] revealed, staff monitored for adverse reactions due to Vancomycin and Resident #1 did not have any changes/remained stable. Her vitals were within range, she had normal body temperature (97.7), blood pressure (118/62), Respiratiosn (17), pulse (72) and her oxygen rate was at 97 %. The nurse received orders for an immediate test of Resident #1's Vancomycin Levels and a BMP. Record review of Resident #1's Progress Notes dated 11/12/25 at 12:35 PM signed by ADON A revealed, Resident assessed for [adverse reactions] to Vancomycin IV. Medical Director in building and updated on Vancomycin administration issue. MDinformed no adverse reaction noted during assessment. New orders received from medical director after viewing resident for STAT Trough (immediate laboratory values) ordered to ensure resident is in therapeutic range with medication. BMP to be drawn tomorrow and redraw for Vanco trough 11/14. Vancomycin to be held until result is received for STAT trough and observed resident q 1hr x 24 hours. NP called and updated on the above. Record review of Resident #1's Lab results dated 11/13/25 revealed, the vancomycin levels came out as low and there were no significant change to her BMP. An observation on 11/12/25 at 11:52 AM revealed, Resident #1 in her wheelchair in the doorway of Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676137 If continuation sheet Page 12 of 18 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 676137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 8902 West Rd Houston, TX 77064 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her room as she received Vancomycin 750 mg/150 ml at 250 ml/hr. (calculated administration duration of 36 minutes). Her left foot was wrapped in a white dressing and her right arm had IV tubing that protruded from under a white gauze dressing. The IV bag had no labeling outside of the manufacturer labeling, there was no pharmacy label that contained the resident's name, dose and instruction for use, administration flow rate, name of prescriber, or date the medication was ordered. The resident was not interviewable, she was confused, tugged on her IV tubing and was combative with staff who passed by. Observation revealed a dial a flow pump. Resident #1 appeared to be in no immediate distress, her skin was not red, she took normal breaths and had no shortness of breath. In an interview on 11/12/25 at 11:54 AM, RN A said the label for Resident #1's Vancomycin must have fallen off after she hung the medication and all medications must have a pharmacy label that includes the residents name, medication information and directions for use. She went to get a new label and when she returned she informed the surveyor the pharmacy label ordered the vancomycin be administered at 750 mg at 150 ml/hr. every 12 hours and she started the infusion at approximately 11:30 AM. RN A said if Vancomycin was administered rapidly a resident could suffer from burning from the IV, she was not aware of any Vancomycin specific infusion reactions. In an observation and interview that started at 11/12/25 at 11:59 AM, the DON said Vancomycin must be administered at the ordered rate because rapid infusion of Vancomycin can result in red man syndrome which could result in flushing (redness), hypotension and cardiac arrest. The surveyor notified the DON of Resident #1's Vancomycin being administered at 250 ml/hr. instead of 150 ml/hr. The DON immediately located Resident #1 in the dining room (the IV was set at 150 ml/hr. when the resident was found in the dining room), returned her to her bedroom and began assessing the resident. The IV was stopped at 12:07 PM, then the DON checked Resident's upper torso for redness and hives to which there was none and Resident #1 began to question what the DON was doing and resist the assessment. Resident #1 appeared to be in no immediate distress, her breathing was normal, she had no redness. In an interview on 11/12/25 at 12:20 PM, the Medical Director said residents that received Vancomycin rapidly could suffer from Red Man Syndrome which is a Vancomycin infusion reaction that can result in tinnitus (ringing/buzzing or hissing in the ear caused by no external source), changes in vitals like hypotension, tachycardia, chest pain, shortness in breath caused by angioedema (swelling in the skin affecting the face, lips, tongue and throat). He said if a resident received Vancomycin at a rate higher than ordered, he expected the IV to be stopped immediately, the resident assessed and the provider notified immediately for orders. He said Vancomycin administered at an incorrect rate was considered a significant medication error but Resident #1 was assessed and suffered no harm. The resident was stable, and labs were ordered to check her Vancomycin level. In an interview on 11/12/25 at 12:28 PM, the DON said Resident #1 was assessed and she had no SOB, Discomfort, irritation at IV site, no pain and her vitals were within normal limits. She said when IV medication was administered nursing staff reviewed the order, retrieved supplies, notified the resident of the medication being administered, performed hand hygiene, donned the appropriate PPE, flushed the line and connected the IV medication following proper infection prevention techniques. The DON said the flow rate was determined by the orders on the bag and failure to administer IVs as ordered could result in adverse drug reactions. She said a significant med error was when an error made could be critical, and caused a significant change in a residents condition. The DON said when a resident experienced a significant medication error, the medication should be stopped immediately, the resident must be immediately assessed and the provider notified. In an observation and interview in the medication room on 11/12/25 at 12:43 PM, the DON said all IV medications should have a pharmacy label that included the pharmacy's information, resident's name, medication information (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676137 If continuation sheet Page 13 of 18 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 676137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 8902 West Rd Houston, TX 77064 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and directions for use. A bag of Resident #1's IV Vancomycin was observed in the fridge with each IV bag wrapped in a foil manufacturer bag and an attached pharmacy label with pharmacy information, resident information, provider information, drug information and directions for use. The label read Vancomycin 750 ml: Infuse intravenously 150 ml (750 mg) over 60 minutes every 12 hours for 10 days. The DON said failure to label medication could result in staff being unaware of the instructions for use including the dosing. In an interview on 11/12/25 at 01:11 PM, RN A said she started working in the facility in 10/2025. She said before medication was administered via IV, staff are verified the order, retrieved the medication from the med room, assessed the resident, flushed the line, connected the IV, and then set the flow rate per the instructions on the IV label. RN A said the facility had two methods of administering IVs, an IV pump which came from the pharmacy or Dial-a-flow tubing which had a dial on the tubing to set the administration rate. She said nursing staff were expected to double check the flow rate prior to starting the infusion and then monitor the resident for at least 15 minutes after the infusion started to ensure the resident did not suffer from an adverse drug reaction. RN A said, a significant med error was this one (Resident #1's vancomycin administration outside of pharmacy orders) and she had not received any training on significant medication errors prior to starting her position on the flow. She said when a resident suffered from a significant medication error they must stop the medication immediately, assess the resident, report the error to the DON/NP, and await instructions. She said she was not educated about the specific infusion reactions that could occur with Vancomycin infusion rates and after the surveyor notified her of the wrong rate Resident #1 received she immediately changed the flow rate to 150 ml/hr. but she did not assess the resident. RN A said she did not follow the appropriate procedures for a significant medication error because she did not stop the infusion, Resident #1 was not assessed, but instead the rate was lowered and the resident was moved to the dinning room with no observations completed. She said she was not trained and did not know what assessments had to be completed for vancomycin infusion reactions, she had not received training on how to use dial-a-flow tubing and she had not received any training on IV medication administration. RN A said no one had completed a skills assessment of her administration of IV medications and prior to working at the facility she was a nurse that worked from home. She said Resident #1 was her first experience with the dial-a-flow tubing. In an interview on 11/12/25 at 02:16 PM, RN A said she knew Resident #1's Vancomycin was ordered at 150 ml/hr. and she intentionally administered the medication against physician's orders at 250 ml/hr. She said she did not notify members of nursing management when she changed the administration rate. RN A said when she checked the medication room there was no medication pump she could use and since Resident #1 was so combative she wanted to ensure Resident #1 received the antibiotic because nothing else had worked. RN A said she was not aware resident's could suffer from an infusion reaction but now she was aware. In an interview on 11/12/25 at 02:40 PM, ADON B said between 9:00 and 10:00 AM RN A asked her if IV vancomycin had to be administered using a medication pump. She said yes and when RN A checked the facility there was no pump available so she instructed RN A to not administer the medication and wait for pharmacy to deliver the pump. ADON B said Vancomycin had to be administered by a pump due to its toxicity/narrow therapeutic window because the pump ensured the resident received the right dose for safety reasons. In an interview on 11/12/25 at 02:53 PM, the NP said when she prescribed vancomycin the pharmacy calculated the rate of administration and nursing staff were expected to administer the medication per the pharmacy orders. She said when Vancomycin was administered rapidly, residents could suffer from VIR (vancomycin infusion reactions) which caused rash, hypotension and tachycardia. She said RN A's failure to administer Vancomycin as ordered was a safety concern because her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676137 If continuation sheet Page 14 of 18 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 676137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 8902 West Rd Houston, TX 77064 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few role as a nurse was to follow orders as written. In an interview on 11/12/25 at 03:30 PM, the Pharmacist said the administration rate of Resident #1's Vancomycin was determined by the manufacturers recommendation to be administered over 1 hour and she was ordered to receive the 750 mg dose in the 150 ml solution at 150 ml/hr. He said if Vancomycin was administered too fast a resident could suffer from a pretty bad reaction and they could experience hypotension, tachycardia and cardiac arrest. The pharmacist said nursing staff are expected to follow the pharmacy ordered rate and it was labeled pretty clearly. He said even though RN A did not administer the medication as ordered it was a low risk for an adverse reaction. Record review of the facility policy Identifying and Managing Medication Errors and Adverse Consequences revised 04/2007 revealed, Policy Statement: The staff and practitioner shall try to prevent medication errors and adverse medication consequences, and shall strive to identify and manage them appropriately when they occur. Policy Interpretation and Implementation: 1. The staff and practitioner shall strive to minimize adverse consequences by: 1. Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication; 2. Defining appropriate indications for use. 2. The staff shall report clinically significant adverse medication consequences and medication errors with adverse clinical consequences to the resident's Attending Physician immediately. 3. In the event of a clinically significant adverse medication consequence, nursing staff shall implement and follow any related Physician orders, and shall monitor closely and document the resident's condition and response to any corrective interventions for at least the next 24 hours or as otherwise directed. 4. Nursing staff will document appropriately detailed accounts of any incidents on an appropriate report form. 5. The Medical Director, Director of Nursing Services, and Consultant Pharmacist shall review medication errors and adverse medication consequences as part of the facility's Quality Assurance process. Record review of the facility policy titled Administration of Drugs and Fluids, Intravenous revised 05/2021 revealed, POLICY: It is the policy of this facility that medications shall be administered as prescribed by the attending physician. PROCEDURES: 1. Only licensed medical and nursing personnel or other lawfully authorized staff members may prepare, administer, and record the administration of medications. 2. Medications must be administered in accordance with the written orders of the attending physician. 8. Verify that the container's label coincides with the prescriber's order. Verify content, dose, prescribed rate, and expiration date of the solution. The seven rights of medication administration are as follows in order to ensure safety and accuracy of administration. 1. Right Resident Resident is identified prior to medication administration; 2. Right Time - Medications are administered within prescribed time frames. 3. Right Medication - Medications are checked against the order before they are given. 4. Right Dose - Medications are administered according to the dose prescribed. Record review of the manufacturer's Highlights of Prescribing Information revised 05/2021 revealed, Infusion Reactions: Hypotension, including shock and cardiac arrest, wheezing, dyspnea (shortness of breath), urticaria (hives), muscular and chest pain and red man syndrome which manifests as pruritus (itching) and erythema (redness) that involves the face, neck and upper torso may occur with rapid intravenous administration. To reduce the risk of infusion reactions, administer Vancomycin Injection over a period of 60 minutes or greater and also prior to intravenous anesthetic agent. ADVERSE REACTIONS: The common adverse reactions are anaphylaxis, red man syndrome, acute kidney injury, hearing loss, neutropenia (low type of white blood cell). Record review of the facility policy Administering Medications revised 05/18/2023 revealed, Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676137 If continuation sheet Page 15 of 18 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 676137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 8902 West Rd Houston, TX 77064 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete and/or have related functions. 3. Medications must be administered in accordance with the orders, including any required time frame. 6. The individual administering the medication must check the label to verify the right medication, right dosage, right time and right method (route) of administration before giving the medication. 20. New personnel authorized to administer medications will not be permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility. Event ID: Facility ID: 676137 If continuation sheet Page 16 of 18 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 676137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 8902 West Rd Houston, TX 77064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, the expiration date when applicable and stored all drugs and biologicals in locked compartments and under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 4 residents ( Resident #1) reviewed for medication storage. RN A failed to ensure Resident #1's Vancomycin IV was labeled when she administered the medication on 11/12/25. This failure could place residents at risk of incorrect medication administration and adverse reactions to medications. Findings included: Record review of Resident #1's Face Sheet dated 11/12/25 revealed, a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: COPD (group of lung diseases that block airflow cause difficulty breathing), muscle weakness, depression, difficulty walking, right great toe amputation, lower left leg open wound and peritoneal abscess (pus within the abdomen due to an infection). Record review of Resident #1's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, fluctuating behaviors of: inattention, disorganized thinking and altered level of consciousness. Behavioral symptoms of: physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing), Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, , or verbal/vocal symptoms like screaming, disruptive sounds) were marked as Behavior not exhibited. Rejection or care and wandering were marked as: Behavior not exhibited. Record review of Resident #1's undated Care Plan revealed, focus: COPD (Chronic Obstructive Pulmonary Disease) r/t SOB, use of medications. Focus: Is on IV Vancomycin HCl Intravenous Solution Reconstituted 750 MG (Vancomycin HCl) r/t leukocytosis (elevated white blood cell count indicating infection). Goal: Will not have any complications related to IV Therapy through the review date. Focus created on 09/16/24 and revised on 09/29/25: [Resident #1]exhibits Behaviors r/t Elopement risk/wanderer, disoriented to place, wanders aimlessly, refuses ADL care/showers frequently. Yells out at other residents. Removes her wound bandages, removes her colostomy bag. Record review of Resident #1's Oder Summary Report dated 11/12/25 revealed, Vancomycin HCl Intravenous Solution Reconstituted 750 MG (Vancomycin HCl) Use 750 mg intravenously every 12 hours for abnormal lab for 10 Days; start date 11/11/25. Record review of Resident #1's November 2025 MAR revealed, the first dose of Vancomycin Resident #1 received was administered by RN A on 11/12/25 at 11:21 AM. An observation on 11/12/25 at 11:52 AM revealed, Resident #1 in her wheelchair in the doorway of her room as she received Vancomycin 750 mg/150 ml at 250 ml/hr. (calculated administration duration of 36 minutes). Her left foot was wrapped in a white dressing and her right arm had IV tubing that protruded from under a white gauze dressing. The IV bag had no labeling outside of the manufacturer labeling, there was no pharmacy label that contained the resident's name, dose and instruction for use, administration flow rate, name of prescriber, or date the medication was ordered. In an interview on 11/12/25 at 11:54 AM, RN A said the label for Resident #1's Vancomycin must have fallen off after she hung the medication and all medications must have a pharmacy label that included the residents name, medication information and directions for use. She said failure to have a label could result in individuals not knowing what the medication was or how it should be administered. In an observation and interview in the medication room on 11/12/25 at 12:43 PM, the DON said all IV medications should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676137 If continuation sheet Page 17 of 18 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 676137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation Center - 8902 West Rd Houston, TX 77064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete have a pharmacy label that included the pharmacy's information, resident's name, medication information and directions for use. A bag of Resident #1's IV Vancomycin was observed in the fridge with each IV bag wrapped in a foil manufacturer bag and an attached pharmacy label with pharmacy information, resident information, provider information, drug information and directions for use. The label read Vancomycin 750 ml: Infuse intravenously 150 ml (750 mg) over 60 minutes every 12 hours for 10 days. The DON said failure to label medication could result in staff being unaware of the instructions for use including the dosing. Record review of the facility policy titled Infusion Therapy Product Labels revised 11/13/2018 revealed, Policy: Infusion therapy products are labeled in accordance with facility requirements and applicable state and federal laws. The label includes sufficient additional information as required to assure safe and efficient administration to residents. Procedures: a. Infusion therapy products are labeled by the provider with: 1) Resident name; 2) Physician name; 3) Pharmacy name, address, and telephone number 4) Contents of solution, including: a) Name of diluent (e.g., NS); b) Name and amounts of each additive; 5) Date dispensed 6) Directions for administration ; 7) Prescription number; 8) Storage instructions; 9) Expiration date and time; 10) Initials of dispensing pharmacist. Event ID: Facility ID: 676137 If continuation sheet Page 18 of 18