Health inspection·December 13, 2023

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few system indicated that on Monday, 12/11/2023 RN F administered the order to, CHANGE & DATE O2 TUBING, HUMIDIFIER BOTTLE, & NEB MASK. CLEAN FILTER ON CONCENTRATOR every night shift every Mon **KEEP INSIDE PLASTIC BAG WHEN NOT IN USE. Observation on 12/11/2023 at 11:19 AM, Resident #6 was in his room with oxygen being administered via nasal cannula, while in bed. An oxygen concentrator via electric wall outlet was present to the left side of the bed providing oxygen to Resident #6. The humidifier bottle was attached to the front of the oxygen unit and displayed a date of 12/5/2023 with no date observed on the oxygen tubing. In an interview and observation on 12/12/2023 at 7:44 AM, Resident #6 was in his room with oxygen being administered via nasal cannula, while seated in his wheelchair at the bottom of his bed. The humidifier bottle was out of the holding location on the front of the oxygen unit and was on the floor. The humidifier bottle displayed a date of 12/5/2023 with no date observed on the tubing. Resident #6 stated they did not come in last night to change his oxygen tubing or humidifier bottle. Resident #6 stated they change out his oxygen tubing and humidifier bottle usually once a week. Observation on 12/13/2023 at 9:15 AM, Resident #6 was in his room with oxygen being administered via nasal cannula, while resting in his bed. The humidifier bottle was on the floor and displayed a date of 12/5/2023, with no date observed on the tubing. In an interview on 12/13/2023 at 10:10 AM, ADON A stated that oxygen tubing and humidifier bottles were changed weekly by the nighttime nurse. ADON A stated that oxygen tubing and humidifier bottles are primarily changed every Monday night by the nurse but stated that they must do so every seven days. ADON A stated that once changed they are to date the tubing near the connection points and on the humidifier bottle if it was disposable. ADON A stated that once the change is complete that the nurse is to log the administration in the MAR. ADON A stated that failure to follow procedures for changing and dating of oxygen tubing and humidifier bottles could result in infection and the oxygen lines becoming dirty. In an interview and observation on 12/13/2023 at 10:14 AM, ADON A was taken to the room of Resident #6 who was not present. ADON A immediately stated that the humidifier bottle should not be on the floor and placed it back in the mounting location on the front of the oxygen machine. ADON A checked the tubing as well as the humidifier bottle, which she stated all displayed a date of 12/05/23. ADON A pointed out to Surveyor that the oxygen tubes did have dates written in them in very fine black print. Surveyor observed that the tubes did display a date of 12/05/2023. ADON A stated that the oxygen tubing and humidifier were not changed out per policy because today (12/13/23) marked eight days of use by Resident #6. ADON A was shown the entry on 12/11/23 by RN F indicating that the oxygen tubing and humidifier bottle were changed. ADON A stated that she did not know why RN F indicated administration because it was obviously not changed. ADON A stated inaccurate documentation by RN F posed a risk because it made it appear that the administration took place if reviewed by the facility through the MAR. In an interview on 12/13/2023 at 10:25 AM, the DON stated that it is their policy to change and date oxygen tubing and humidifier bottles no less than every seven days. The DON stated that unless otherwise ordered the oxygen tubing changes are completed by their nurses' every Monday night. The DON stated that failure to change tubing and the humidifier bottle every seven days posed an infection control risk and could result in the humidifier bottle running out of water. Surveyor attempted to show the DON the failure with Resident #6's tubing but she stated that she had been informed and that it had been changed. The DON reviewed the MAR and stated that RN F needed to be in serviced. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676238 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 676238 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation - North 11020 Dessau Rd Austin, TX 78754 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm stated that improper logging of administration could make it appear that the tubing and humidifier bottle were changed, which posed an infection control risk. On 12/13/2023 at 11:07 AM, Surveyor attempted to interview RN F, but she was unavailable and never contacted Surveyor back after being requested to do so. Residents Affected - Few In an interview on 12/13/2023 at 12:17 PM, the ED stated that he was notified of the failure to replace and date the oxygen tubing and humidifier bottle for Resident #6 and that it should not have happened. The ED stated that this failure posed an infection control risk. The ED was notified of the inaccurate administration enter on their MAR by RN F. The ED stated that they have completed in-services for Oxygen and MAR entry but stated that RN F started her employment after the last training that was completed. Review of facility in-service on 07/09/2023 For Nurses Only with the subject: TAR (Treatment Nurse) / Mars; Report, o2 tubings revealed in notes, 4. NIGHT SHIFT: You are responsible for changing resident's O2 humidifier, nebulizer masks wiping O2 concentrators, changing and dating nasal cannula including resident that uses portable O2 during the day, EVERY MONDAY NIGHT . Review of the facility's Policy / Procedure - Nursing Clinical, Subject: Oxygen Administration (Mask, Cannula, Catheter) dated as revised 05/2007 read, Policy: It is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can be obtained. Purpose: The purpose of the oxygen therapy is to provide sufficient oxygen to the blood stream and tissues. Equipment: Pressurized oxygen cylinder and stand or oxygen via wall outlet or oxygen concentrator or liquefied O2 canister, Nasal cannula or oxygen, Oxygen tubing, Pre-filled or reusable Humidifier, Distilled water. Procedure: 8. If using a reusable humidifier, fill bottle to the correct level with distilled water and attach to oxygen unit. INSTRUCTIONS FOR TUBING AND HUMIDIFER CHANGES: 1. Oxygen tubing is to be replaced every seven (7) days. Oxygen masks or nasal prongs are to be replaced every seven (7) days. 2. Replace disposable humidifiers as needed when empty. 3. Refill non-disposable humidifiers with distilled water, as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676238 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 676238 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation - North 11020 Dessau Rd Austin, TX 78754 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, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 6 (#90 and #256) Residents reviewed for infection control practices. Residents Affected - Few CNA D failed to use proper hand hygiene techniques when proving perineal incontinence care for Resident #90 and #256. These failures had the potential to affect all residents in the facility by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that could lead to the spread of communicable diseases. Findings included: A) Record review of Resident #90's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Arnold Chiari Syndrome with Hydrocephalus (a condition in which the brain tissue extends into the spinal canal with swelling of the brain), essential hypertension (high blood pressure), Parkinson's disease (a disorder of the central nervous system that affects movement), and major depressive disorder. Record review of Resident #90's annual MDS assessment dated [DATE] reflected the resident had a BIMS score of 9 indicating the resident was cognitively moderately impaired. The MDS also reflected the resident required extensive assistance in various areas of activities of daily living such as bed mobility, dressing, and toilet use. Record review of Resident #90's care plan dated 03/09/23 reflected Resident #90 was care planned for her bowel and bladder incontinence related to impaired mobility. Resident #90's care plan included interventions to monitor for symptoms of urinary tract infection. Observation on 12/12/2023 at 1:54 PM of urinary incontinent care performed on Resident #90 reflected CNA D failed to use hand hygiene during peri care when changing her gloves between clean and dirty incontinent brief. B) Record review of Resident #256's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of displaced fracture of lateral malleolus of the left fibula (left hip fracture), Type 2 Diabetes (a chronic condition that affects the way the body processes blood sugar), and Muscle Wasting and Atrophy (decreased muscle tone) Record review of Resident #256's MDS assessment dated [DATE] reflected the resident had a BIMS score of 15 indicating the resident was cognitively intact. The MDS also reflected the resident required extensive assistance in various areas of activities of daily living such as bed mobility, dressing, and toilet use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676238 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 676238 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation - North 11020 Dessau Rd Austin, TX 78754 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 Record review of Resident #256's care plan dated 07/27/23 reflected Resident #256 was care planned for her bowel and bladder incontinence related to impaired mobility. In an observation of CNA D on 12/12/23 at 2:15pm CNA D removed Resident #256 soiled brief, removed soiled gloves from her hands and immediately applied clean gloves failing to perform hand hygiene between dirty and clean gloves. In an interview with CNA D on 12/12/23 at 2:31pm she reported she knows she is supposed to use her alcohol-based gel or wash her hands between glove changes, but she had just forgot. She reported the staff had been checked off visually on performing peri care and hand hygiene by the ADON. She states that not cleaning hands between gloves could place the resident at risk for infection. In an interview on 12/12/23 at 2:44pm with RN C (charge nurse for CNA D) he reported it is the expectation that the CNA would either wash their hands or use the alcohol gel between glove changes to sanitize their hands. He reported the staff are trained in in-services frequently and then 1 time yearly they are all checked off in skills fair on everything. RN C reported the risk of not cleaning hands between gloves to the resident would be urinary tract infection. In an interview with ADON B on 12/13/23 at 9:46am he reported all staff are visually checked off in a skills lab yearly for hand hygiene and perineal care, as needed and upon hire. He stated he would have expected the staff to wash her hands in-between each glove change. He reported the risk to the resident for not changing gloves is infection. ADON B states he and DON are responsible for monitoring and training all nursing staff related to peri care and hand hygiene. In an interview with DON on 12/13/23 at 10:47am she reported all staff just did skills check off in September that included hand hygiene and peri care. She stated staff were educated upon hire and annually. The DON reported it's expected for all staff to clean their hands between gloving from dirty to clean. The risk to the resident for not having clean hands would be infection and illness. Nursing administration is responsible for educating and monitoring the staff on peri care and hand hygiene. Record review for hand hygiene policy dated 5/2007 last update 10/2022, reflected staff should perform hand hygiene after removing gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676238 If continuation sheet Page 5 of 5