Health inspection·February 5, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few family of the improper transfer. The DON stated CNA A was written up and was trained by the staff developer personnel. The DON stated random training mechanical transfers were being done by the management staff. During interviews on 02/05/2025 from 11:53 am to 4:22 pm, CNAs C, B and E, RNA F, RN G, the Staffing Coordinator, the Wound Care nurse and the Central Supply, all staff stated 2 persons were required for mechanic lift transfer for Residents safety. Staff stated they have completed checkoffs on mechanical lift transfers. On 02/05/2025 CNA A was unavailable for interview due to travel status. Review of CNA A's personnel file reflected: Counseling/Disciplinary Notice dated 01/12/2025, written warning reason---failure to perform duties directly related to or engaging in conduct that in any way compromises the safety, health and/or physical comfort and well-being of a Resident. Corrective action-skills checkoff on mechanical lift transfer. It was also reflected the document was signed by CNA A. Review of a performance review dated 01/12/2025 and signed by CNA A and the Medical Record/Staffing coordinator reflected CNA A received her approval for all aspects of her performance of a mechanical lift transfer, including the following: Gather assistance of at least one staff member prior to beginning, transfer and communicating expectations of transfer, prearranged signals, and plan to complete transferred together. Review of the facility's policy dated June 2018 titled Fall Management System reflected the following: The facility is committed to providing resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practical level of function through providing the resident adequate supervision, assistive devices and functional programs as appropriate to prevent accidents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676238 If continuation sheet Page 2 of 9 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 02/05/2025 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 observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 2 of 4 residents (Resident #1 and Resident #2,) reviewed for infection control. Residents Affected - Some CNAs B, C, and D failed to properly perform incontinent care on Residents #1 and 2. CNA D failed to perform hand hygiene while performing incontinent care on Resident #2. The facility failed to wear PPE when providing high contact resident care (dressing, bathing, transfers, wound care, device) to Resident #2. The facility failed to have signage on resident door that reflected PPE was required for high contact care for Resident #2. These failures could place residents at risk for infection, hospitalization, or death. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included dementia, cognitive communication deficit, and need for assistance with personal care. Review of the quarterly MDS assessment for Resident #1 dated 10/25/24 reflected a BIMS score of 1, indicating severe cognitive impairment. It reflected she was totally dependent on staff for toileting hygiene. Review of the care plan for Resident #1 revised 04/24/24 reflected the following: [Resident #1] has ADL Self Care Performance Deficit, will maintain current level of functioning in Bed Mobility, Transfers, Eating, Toileting. Toilet use: requires assistance, extensive X1 person. Observation of a closed-circuit video dated 01/08/2025 at 1:30 pm revealed CNA C began peri care (know as perineal care-involves cleaning the private areas of a patient/Resident) on Resident #1, with gloved hands, CNA C took wipes from the packet, wiped Resident #1's left groin (located at the junction where the upper body or the abdomen meets the thighs) area down and vaginal area with the same wipes 3 times without folding or changing wipes. CNA C did not separate Resident #1's labium (the inner and outer folds of the vulva, at either side of the vagina) to clean properly. CNA C did not clean Resident #1's right groin area. CNA C then rolled Resident #1 over on her left side, wiped Resident #1's buttocks in an upward motion multiple times with the same wipes without changing or folding the wipes. Observation of a closed-circuit video dated 01/08/2025 at 1:30 pm revealed CNA B began peri care on Resident #1, with gloved hands, CNA B took wipes from the packet, wiped Resident #1's lower abdominal area from left to right and down to Resident #1's vaginal area with the same wipes without folding or changing the wipes. CNA B then rolled Resident #1 over on her left side, removed soiled brief, wiped Resident #1's buttocks in an upward motion 2 times with the same wipes without changing or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676238 If continuation sheet Page 3 of 9 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 02/05/2025 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 folding the wipes. Level of Harm - Minimal harm or potential for actual harm Review of the undated face sheet for Resident #2 reflected an [AGE] year-old female admitted to the facility on [DATE] with readmission date of 01/30/2025. Her diagnoses included metabolic encephalopathy (a condition where problems with metabolism cause brain dysfunction, can lead to symptoms such as confusion and memory loss) urinary tract infection and need for assistance with personal care. Residents Affected - Some Review of the quarterly MDS assessment for Resident #2 dated 02/03/25 reflected a BIMS score of 0, indicating severe cognitive impairment. Staff assessment reflected short and long-term memory problems. Section H (bladder and Bowel) reflected Resident #1 had indwelling catheter (also a foley catheter, a thin, flexible tube inserted into the bladder for an extended period to allow urine to flow freely for collection or testing). Review of the care plan for Resident #2 revised 01/06/25 reflected the following: [Resident #2] has ADL Self Care Performance Deficit, will safely perform Bed Mobility, Transfers, Eating, dressing, grooming personal hygiene and Toileting. Toilet use: incontinent to bowel and bladder, requires total assistance X2 person with incontinent care. It was also reflected, Resident #2 had pressure ulcer or potential for pressure ulcer development (SPECIFY location) related to admitted with Stage 4 to the sacrum, Use Enhanced Barrier Precautions. Review of Resident #2's current physician order reflected the following: CATHETER TYPE: 16FR # 10 ML TO CLOSED URINARY DRAINAGE SYSTEM - DIAGNOSIS FOR USE: neurogenic bladder every shift dated 01/31/2025. ENHANCED BARRIER PRECAUTIONS: PPE required for high resident contact care activities. Indication: Wounds, Urinary Catheter dated 02/03/2025 SACRAL WOUND- Cleanse with Dakins soaked gauze, pat dry, apply collagen flakes to the wound bed, then skin prep around the area, peri wound, place peel and place dressing in place, connect to NPWT continuous at 125mmHg bridge to adjacent anterior lateral left or right if needed. Every day shift every Mon, Wed, Fri for Stage 4 dated 02/05/2025. Observation on 02/05/2025 at about 12:00 noon, revealed CNA C and CNA D went to perform peri care on Resident #2. The was no signage at Resident #2's door or bin containing PPE to indicate Resident #2 was on EBP. It was observed both CNAs did not wear gown to perform incontinent care on Resident #2. CNA D performed hand hygiene, donned clean gloves, and began wiping Resident #2's front. CNA D wiped Resident #2's left groin area multiple times, upward and backward with same wipes, and moved to right side. CNA D removed gloves, no hand hygiene, donned clean gloves, and wiped Resident #2's vaginal area. CNA D then rolled Resident #2 to the right side, wiped Resident #2's buttocks in an upward and downward motion, same wipes without folding the wipes. CNA D then removed gloves, no hand hygiene and donned clean gloves. It was observed Resident #2 had a foley catheter draining, wound at coccyx area with dressing soiled with BM and excoriations at upper thighs. CNA D applied barrier cream to excoriated area at upper thighs, with the same gloved hands CNA D touched the curtains in Resident #2's room. CNA D removed gloves, walked into Resident #2's bathroom, without hand hygiene, touched Resident #2's personal items in a sealed bag, and then washed CNA D hands. During an interview on 02/05/2025 at 1:46 pm, CNA D stated she had been trained on infection control. CNA D stated hand washing was performed just before resident's care and after care, and after (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676238 If continuation sheet Page 4 of 9 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 02/05/2025 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 - Some changing gloves 2-3 times. She stated you can sanitize your hands with gloves changes, but she did not have sanitizer. CNA D stated, when performing incontinent care, staff were supposed to wipe from front to back and the staff could fold the same wipe and use again. CNA D stated when wiping the buttocks area, staff were to wipe in an upward motion, but with resident #2, due to the wound it was hard to wipe her. CNA D stated she had worked with Resident #2 before and was aware she had a foley catheter and wound. CNA D stated she was trained on EBP, if residents had wounds and foley catheter they were supposed to wear gown, but Resident #2 did not have sign on the door or PPE next to the door. CNA D stated they had to wear gowns to prevent the spread of infection, to protect the residents. During an interview on 02/05/2025 at 2:01 pm, CNA C stated she was trained on infection control, hand hygiene, donning PPE. CNA C stated hand hygiene was performed when entering a resident's room, when leaving the room, before and after feeding a resident, and with gloves changes. CNA C stated during incontinent care on Resident #2, when CNA D changed gloves, she should have used a sanitizer, but CNA D did not have a sanitizer. CNA C stated CNA D wiped back and forth because Resident #2 had too much cream sticking on her buttocks area. CNA C stated, when cleaning a resident's front during incontinent care, staff were supposed to wipe downward, and at the back you wipe upward to prevent infection. CNA C stated she was aware Resident #2 had a foley catheter and wounds. She also stated they were trained to wear gown when providing care for residents with foley catheter, wounds, or feeding tube to prevent the spread of infection to and from residents. CNA C stated there were no signage or PPE bin at Resident #2's door that was why they didn't wear gowns. During an interview on 02/05/2025 at 4:00 pm, the Central Supply staff stated she was responsible to ensure residents who met EBP criteria had signage at the door along with bin containing PPE. She stated residents with wounds, foley catheters, or dialysis catheters met EBP criteria. She stated usually it was discussed in the morning meetings, but she was not made aware of Resident #2 needing signage and PPE set up at her door. The Central supply staff stated not having the signage and PPE bin at the doors of residents who met EBP criteria would endanger the residents by exposing them to infection. During an interview on 02/05/2025 at 4:22 pm the DON stated the entire management team was responsible to ensure a residents who met the criteria for EBP got signage and PPE bins were at the door to alert staff. The DON stated upon admission, the team discuss in their morning meetings. The DON stated they had bins and signage setup and ready for backup for the nursing staff for Residents with wounds, foley catheters, GT, etc. The DON stated she was made aware that Resident #2 did not have signage and PPE set up at the door. The DON stated Resident #2 required EBP because of her wounds and foley catheter. The DON stated EBP was to prevent the transmission of infection to the residents. The DON stated hand hygiene should be performed when soiled, when in contact with residents, when moving from dirty to clean, with gloves change . The DON stated it was her expectation for staff to perform peri care according to the facility's peri care procedure. The DON stated staff were not supposed to wipe from the side and same wipe in the vagina area that was exposing the resident to infection. The DON stated staff were not supposed to double wipe or scrub up and down, going in the opposite direction. CNA B was not available for interview. Review of a performance review dated 09/11/2024 and signed by CNA C and the Central Supply staff reflected CNA C received her approval for all aspects of her performance of Hand Hygiene, PPE-DON and Doff, and Peri care-female. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676238 If continuation sheet Page 5 of 9 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 02/05/2025 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 Review of a performance review dated 01/07/2025 and signed by CNA B and the Medical Record/Staffing coordinator reflected CNA B received her approval for all aspects of her performance of Peri care-female. Review of a performance review dated 07/24/2024 and signed by CNA D and the Medical Record/Staffing coordinator reflected CNA D received her approval for all aspects of her performance of Peri care-female. Residents Affected - Some Review of facility's policy titled infection Prevention and Control Program revised 10/2022 reflected: Policy The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the infection prevention and control program consist of coordination/oversight, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. The program will be carried out by the facility infection preventionist. It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards. Goal o Decrease the risk of infection to residents and personnel. o Recognize infection control practices while providing care. o Identify and correct problems relating to infection control. o Ensure compliance with state and federal regulations related to infection control o Promote individual resident's rights and well-being while trying to prevent and control the spread of infection. o (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676238 If continuation sheet Page 6 of 9 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 02/05/2025 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 Monitor personnel health and safety. Level of Harm - Minimal harm or potential for actual harm Review of facility's policy titled Hand Hygiene revised 12/2023 reflected: Policy Residents Affected - Some It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene, which is one of the most effective measures to prevent the spread of infection, based on accepted standards. Residents, family, and visitors will be encouraged to practice hand hygiene. Hand hygiene is a general term that applies to hand washing, antiseptic hand wash, and alcohol-based hand rub. 2. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: g. Before handling clean or soiled dressings, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with blood or bodily fluids; j. After handling used dressings, contaminated equipment, etc.; k. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; .After removing gloves; m. Before and after entering isolation precaution settings; n. Before and after eating or handling food; o. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676238 If continuation sheet Page 7 of 9 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 02/05/2025 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 Before and after assisting a resident with meals; and Level of Harm - Minimal harm or potential for actual harm p. After personal use of the toilet or conducting your personal hygiene. Residents Affected - Some q. After removing and disposing of personal protective equipment. Review of facility's titled Policy/Procedure-Nursing Services: Quality of Care revised 01/2023 reflected: POLICY: It is the policy of this facility that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care. Review of facility's skill checkoff titled Peri Care-Female reflected: Implementation .put on clean gloves. .assemble supplies on clean appropriate surface and allow Resident to test temperature of water (if using) .assist resident into comfortable position with bed at a comfortable level. .ensure pad or linen protector is appropriately under the patient before washing. .apply soap to wet washcloth (skip step if using wipes) .wash genital area moving from front to back, using a clean part of the washcloth for each stroke or a clean wipe for each stroke. .using a clean washcloth, rinse soap from genital area, moving from front to back, using a clean area of the washcloth for each stroke (skip if using wipe) .after cleaning genital area, assist Resident on the side .if using wipe use a clean wipe to clean rectal area, moving from front to back, dry with towel. Review of the Virginia Department of Health - Enhanced Barrier Precautions in Nursing Homes Algorithm, dated 06/2024, reflected in part, EBP are indicated for the following residents who are: Known to be colonized or infected with a multidrug-resistant organism (MDRO) when contact precautions do not otherwise apply; At increased risk of MDRO acquisition (e.g., resident has a wound or indwelling medical device) . In addition to standard precautions, gowns and gloves should be worn during the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676238 If continuation sheet Page 8 of 9 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 02/05/2025 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care . Steps to Implementation: With implementation, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. 1. Post clear signage on the door or wall outside of the resident room indicating the type of precautions and required personal protective equipment (PPE) (e.g., gown and gloves). For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of a gown and gloves. 2. Make PPE, including gowns and gloves, available immediately outside of the resident room . Event ID: Facility ID: 676238 If continuation sheet Page 9 of 9