Health inspection·September 17, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few right hand and arm exposing a bruised on the lower right thumb. Resident #1 stated 0on 08/17/2025 early in the morning she was awakened by CNA A. Resident #1 stated, I told them I wanted to sleep and I'll do it later. She stated CNA B joined CNA A in the room and CNA B (who was the smaller CNA) grabbed my right hand, she pulled my thumb backwards and I screamed. Resident stated, The CNA's came around dinner time and they put me in the wheelchair that's when I noticed my right thumb and right wrist were swollen. Resident # 1 stated, daughter told the staff to send me to the hospital. Interview on 09/03/2025 at 10:40 AM with Residents # 3 (Resident # 1's roommate). Resident # 3 stated, she was in the room and awake at the time of the incident and it was around 7 AM. Resident # 3 stated, Tthere were 2 CNAs in the room that morning. She stated, tThe smaller one came in to help and that's when I heard a loud cry from (Resident # 1). and I couldn't see anything because the curtain was pulled closed but, I knew (Resident # 1) was in pain by the sound of her scream. Interview on 09/03/2025 at 10:50 AM with CNA C she stated, I had cared for (Resident #1) the week before on Thursday, August 14th, 2025, and Friday, August 15th, 2025 and she had no injuries then. He stated, On Monday, August 18th, 2025 (Resident # 1's) hand looked very different than last week, so I knew something was wrong. I immediately told the Nurse about (Resident # 1's) hand. He stated, a Staff Nurse came down to the room to see the resident's injury. He stated, They called Emergency Services came and took her to the hospital, and I didn't see her again until the next day. Interview on 09/03/2025 at 12:29 PM with Family member of Resident # 1. He stated, We had a recording of the morning of the incident, but we could not see the incident because the Aids pulled the curtain around the entire bed. He stated, All I could here is mother yelling and screaming and when they opened the curtain, you can see mom holding her hand. He stated, the family had put a screw on the curtain track to prevent the curtain from being pulled because the staff continued to try and hide from the camera. He stated his mom has dementia and that she doesn't remember details. During an interview with CNA A on 09/04/2025 at 12:35 PM, CNA A said she was suspended due to Resident #1 having a bruise on her left thumb. CNA A said that she had not hurt Resident #1 or any other residents. She said she did not report the injury because it was CNA B who found the injury. She said Resident #1 did not complain of pain to her finger. Observation of Video on 09/03/2025 at 3:10 PM with ADM and DON. ADM shared an approximate 5 minutes of video recorded on 08/17/2025 at 7:11 AM. The video reveals 2 CNA's entering Resident # 1's bed area. CNAs were identified by the ADM and the DON as CNA A and CNA B. CNA A was observed pulling the curtain from the right side of the bed to the left side of Resident # 1's bed. The curtain served to block the view from the camera of the care being performed to Resident # 1. Per the audio of the video, Resident # 1 was heard to be shouting stop . Resident was also heard to scream loudly in a sharp, high pitch. When CNA A reopened the curtain, Resident #1 was observed to have on different clothing and Resident # 1 was positioned on her left side facing the window. CNA A and CNA B were observed to be holding soiled briefs and other soiled items. Observation shows both CNA's leaving the room and the video ended. During an interview with LVN A on 09/15/2025 at 12:36 PM revealed that on the day 08.17.2025 around lunch time, she was on the hallway when CNA B brought Resident #1 to LVN A at the nurse's station. CNA B told her; the resident was not able to use her hand to pick up her personal phone. She said CNA B also told her Resident # 1 could not use her hand properly. LVN A said that CNA B did not know how the injury to Resident #1 occurred. LVN A said she observed the resident's' right hand, and she saw a bruise on the upper part of the resident's right thumb. She said she asked Resident # 1, what happened? Resident # 1 said she did not know what happened and she did not remember. LVN A said she tried to assess the hand, but Resident #1 would not let her touch it. Resident #1 said she was in pain. LVN A said that CNA B told her she did not know what caused the bruises (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676238 If continuation sheet Page 2 of 15 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 09/17/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few to Resident #1. Record review of the facility's Abuse, Neglect, and Exploitation, dated 11/2017, reflected: Training d. Reporting abuse, neglect, exploitation, and misappropriation of residents property, including injuries of unknown sources, and to whom and when staff and others must report their knowledge related to any alleged violation without fear of reprisal. and Abuse: Prevention of and Prohibition Against; Reporting reasonable suspicion of a crime against a resident in accordance with Section 1150B of the social security Act.This was determined to be an Immediate Jeopardy (IJ) on 09/15/2025 at 5:54 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 9/15/2025 at 5:55 p.m. The ADM was asked to submit a Plan of Removal. The following Plan of Removal submitted by the facility was accepted on 09/16/2025 at 4:33 pm.Date of IJ Notification: 09/15/2025 Date/Time IJ Identified by Surveyor: 09/15/2025 at 5:55 PMPlan of Removal - F600 (Abuse) Deficient Practice: The facility failed to ensure that Resident # 1 free from physical abuse. This resulted in the resident having a mildly displaced fracture of the base of the right first digital proximal phalanz with extension to the first digit. Immediate Actions Taken (Date: 09/16/2025):Charge nurse will assess Resident #1 for complications after hospitalization and return from dialysis. Completion date 9/10/2025 Action: CNA A and CNA B suspended pending investigationStart Date: 8/18/2025Completion Date: To be determined when suspension has ended.Responsible: Director of Nurses/Designee Action: Skin Assessments conducted on all residentsStart Date: 8/19/2025Completion Date: 8/19/2025Responsible: DON/Designee Action: Medical Director, Nurse Practitioner and Physician Assistant notification of immediate jeopardy and plan of removal discussed. Start Date: 9/15/2025Completion Date: 9/15/2025Responsible: Executive Director Action: Ad hoc QA meeting. Attendees included ED, DON, Clinical Resource, Clusters Partners, Medical Director. Meeting included the Plan of Removal and interventions.Start Date: 9/15/2025Completion Date: 9/15/2025Responsible: Executive Director Action: Inservice Director of Nursing and Executive Director on Abuse and Neglect Policy Start Date: 9/15/2025Completion Date: 9/15/2025Responsible: Clinical Resource, MSN, Ed, DON Action: Inservice Director of Nursing and Executive Director on Resident Rights Start Date: 9/15/2025Completion Date: 9/15/2025Responsible: Clinical Resource, MSN/Ed, DON Action: Inservice initiated to all staff on Abuse and Neglect Policy to be conducted prior to start of next shift.Start Date: 9/15/2025Completion Date: 09/19/2025 Responsible: DON Action: Safe Surveys conducted on all residents.Start Date: 9/15/2025Completion Date: 9/15/2025Responsible: DON/Designee Action: Inservice of CNA A and CNA B on Abuse and Neglect with knowledge retention demonstrated with post-testStart Date: 9/15/2025Completion Date: 9/15/2025Responsible: DON/Designee Action: Inservice of CNA A and CNA B on Abuse and Neglect with knowledge retention demonstrated with post-testStart Date: 9/15/2025Completion Date: 9/15/2025Responsible: DON POR monitoring conducted on 9/16/2025 and 9/17/2025. Record review of IJ Binder on 9/16/2025 CNA A and CNA B have been terminated, and the termination is in the binder. Copies have been scanned. The Abuse Policy for Freedom from abuse, neglect, & exploitation, Residence, rights & responsibilities were in the binder. Verified that the email was sent to the ombudsman notifying them of the IJ. Verified that QAPI was done with the executive director, Director of Nursing, and clinical resources, and signed by each of them Residence safety surveys were completed In service on resident rights and abuse and neglect was given to the administrator in the DON by MSN/ED, RN clinical resources. In-service training completed by all staff on abuse and neglect, and resident rights. All staff or quiz on resident rights, abuse and neglect Staff contacted the resident #1s daughter to verify that they had notified her of the immediate jeopardy During an Interview with Resident #14 at 12:12 PM Resident # 14 Revealed he has never been injured by a staff member when he is getting care. Resident #14 said he has no concerns about the staff and that they treat him well. Resident #14 likes it at the facility. There (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676238 If continuation sheet Page 3 of 15 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 09/17/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few were no other concerns at the time. During an interview with Resident #18 at 12:16 PM , He revealed he felt safe at the facility. Resident #18 said he has never been abused or injured by any staff at the facility. Resident #18 said that all the staff treat him well. Resident #18 said that he likes the care he is getting at the facility. During an interview with Resident #10 at 12:25 PM he revealed he feels safe at the facility. Said he has never been abused or injured by the staff. Resident #10 said that he likes the care that he is getting, and it is better than the care he was getting at the last facility. There were no other concerns at the time. During an interview on 09/17/2025 3:21 PM, ADM revealed per Abuse policy, suspected abuse should be reported immediately to him. If ADM is not available, staff member who could report it to ADON, DON, or management. LMS education portal before they start, and continuing education quizzes and refreshers. It was serviced yesterday. Has not witnessed any abuse in the facility. ADM said to prevent this from happening, he has staff get extra training and keep telling them about abuse. During an interview on 09/17/2025 3:04 PM, DON revealed, the facility is to use the provider letter when it is reportable and follow the 24-hour guidelines. All staff are required to notify the DON or the Nurse, and they will tell ADM. If there is an allegation pending investigation. Upon hire, reliance training it covers abuse and neglect. And that covers dementia care. All the training is annual. In-service on abuse yesterday, and before that was in August. Payday in-service for abuse. Has not witnessed abuse in the facility. More training on residents' rights and the right to refuse care and more training on that and cooperative residents. During an interview on 9-17-2025 at 2:15 PM RN said that if there is abuse, then is should be reported immediately. RN said abuse should be reported to the ADM or the DON. RN said that they get in-service training on abuse and neglect through videos, in person, and emails. The last in-services on abuse and neglect were 9-16-2025 and 9-16-2025. RN has not witnessed any abuse or neglect in the facility. During an interview on 09/17/2025 2:26 PM, CNA D said that if she sees abuse in the facility, then she is to report it immediately to the ADM, who is the abuse and neglect coordinator. CNA D has not witnessed abuse or neglect in the facility. CNA D said that she had in-service training on abuse and neglect, and the last time was 9-16-2025. CNA D said that she gets in-service training regularly for abuse and neglect. videos and meetings. CNA D has not witnessed abuse or neglect in the facility. During an interview on 09/17/2025 2:00 PM LVN B said if she sees abuse in the facility, she reports it immediately to the ADM, who is the abuse and neglect coordinator. LVN B said she has not witnessed any abuse in the facility. LVN B said that she gets in-service regularly on abuse. LVN B said the last time she had abuse training was 9-16-2025. LVN B said that get in-service training in person and videos. During an interview on 09/17/2025 2:06 PM, CNA 5 said she has not witnessed abuse or neglect in the facility. CNA 5 said if she sees abuse in the facility, then she tells the ADM. CNA 5 said the last time she had in-service training on abuse was on 9-16-2025. CNA 5 said she gets in-service training by video and in person. CNA 5 said that there is usually a test after. Training Monday, test Tuesday, and last week, and the video was at the beginning of the month. During an interview on 09/17/2025 2:00 PM, ADON revealed that abuse should be reported immediately to the ADM. If the ADM is not available, then it would be reported to the DON ADON stated that they he has received training on abuse regularly and the last time was on 9/16/2025. ADON stated he gets training in person, online, and they watch videos. To prevent abuse Human Resources does a background check on new employees. ADON said he has not witnessed any abuse or neglect in the facility. An IJ was identified on 09/15/2025. The Administrator was notified and an IJ Template was provided on 09/15/2025 at 5:55 p.m. While the Immediate Jeopardy was removed on 09/17/2025 at 4:33 pm, The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676238 If continuation sheet Page 4 of 15 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 09/17/2025 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 0600 scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676238 If continuation sheet Page 5 of 15 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 09/17/2025 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for one of one resident (Resident #1) reviewed for abuse, neglect, and exploitation. The facility failed to implement their policies and procedures to ensure Resident #1 was free from abuse when the facility failed to have effective interventions and services in place to address the resident's care, which resulted in Resident #1 sustaining Comminuted (bone that is broken in at least two places),(mildly displaced fracture of the base of the right first digital proximal phalanz (most basal bones of each digit.)with extension to the first digit joint time stamped 08.18.25 @ at 13:57 pm, reported signed by Doctor. An IJ was identified on 09/15/2025. The Administrator was notified and an IJ Template was provided on 09/15/2025 at 5:55 p.m. While the Immediate Jeopardy was removed on 09/16/2025 at 4:33 pm, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.The failure could place residents at risk for serious injuries, hospitalization, and death. Finding includes:Record review of Resident #1's admission Record, dated 09/03/25, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Unspecified Dementia, moderate (This is when symptoms become more severe, and the individual's ability to perform daily tasks declines significantly.), Hypertensive Heart (refers to heart conditions caused by high blood pressure.) and Chronic Kidney Disease (Gradual loss of kidney function.). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of was 4 indicating severe cognitive impairment. The MDS revealed Resident # 1 was dependent on staff for all ADLs. Record review of Resident #1's care plan dated 07/02/2025 revealed Resident #1 had potential to demonstrate physical behaviors related to dementia. Goal: Will not harm self or others through the review date. Interventions: Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Record Review of Resident # 1's Weekly Skin Assessment on 08/15/2025 at 12:54 PM reflected left great toe abrasion and lateral ankle trauma wound present and no other skin issues noted.Record review for Change of Condition for Resident # 1's Skin Assessment on 08/17/2025 at 3:05 PM documents Bruise and swelling to right thumb.Record review for Change of Condition for Resident # 1's Skin Assessment on 08/17/2025 @at 3:05 PM documents Record review for Change of Condition for Resident # 1's Skin Assessment on 08/17/2025 @at 3:05 PM documents Bruise and swelling to right thumb.Record Review of Provider Investigation Report on dated 8/18/2025 reflected, that CNA B upon getting resident up in her wheelchair, she noticed her right thumb was swollen and was unable to hold her phone while receiving a call from son. The Provider Investigation Report does did not indicate how this injury occurred. The Provider Investigation Report stated incident occurred 08/17/25 at 11:50 AM and assessment was done on 08/17/2025 @ at 3:35 PM. The assessment reported bruising and edema to right thumb. 08/18/2025 Resident # 1 was transferred at 10:30 AM offsite to [St. [NAME] local hospital]. Incident was reported by ED to Texas Health and Human Services complaint and Incident Intake via email on 08/18/2025 at 7:20 PM.Record review of CNA B's statement revealed on 08/17/2025 CNA A assisted CNA B in changing Resident # 1's brief. CNA B stated, I assisted Resident # 1 by crossing her arms across her chest to roll her onto her left side. Record review of ER medical report for Resident # 1 service date 08.18.25 at 12:56 PM. Findings:Xray Impression: Comminuted (bone that is broken in at least two places) ( mildly displaced fracture of the base of the right first digital Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676238 If continuation sheet Page 6 of 15 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 09/17/2025 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few proximal phalanz (most basal bones of each digit,)with extension to the first digit joint time stamped 08.18.25 @ at 13:57 pm, reported signed by Doctor. Interview & Observation of Resident # 1 on 09/03/2025 at 10:35 AM. revealed Observed Resident #1 lying in bed, she raised her right hand and arm exposing a bruised on the lower right thumb. Resident #1 stated 0on 08/17/2025 early in the morning she was awakened by CNA A. Resident #1 stated, I told them I wanted to sleep and I'll do it later. She stated CNA B joined CNA A in the room and CNA B (who was the smaller CNA) grabbed my right hand, she pulled my thumb backwards and I screamed. Resident stated, the CNA's came around dinner time and they put me in the wheelchair that's when I noticed my right thumb and right wrist were swollen. Resident # 1 stated, My daughter told the staff to send me to the hospital. Interview on 09/03/2025 at 10:40 AM with Residents # 3 (Resident # 1's roommate). Resident # 3 stated, she was in the room and awake at the time of the incident and it was around 7 AM. Resident # 3 stated, There were 2 CNAs in the room that morning. She stated, the smaller one came in to help and that's when I heard a loud cry from (Resident # 1). and I couldn't see anything because the curtain was pulled closed but, I knew (Resident # 1) was in pain by the sound of her scream. Interview & Observation of Resident # 1 on 09/03/2025 at 10:35 AM. revealed Observed resident #1 lying in bed, she raised her right hand and arm exposing a bruised on the lower right thumb. Resident #1 stated 0on 08/17/2025 early in the morning she was awakened by CNA A. Resident #1 stated, I told them I wanted to sleep and I'll do it later. She stated CNA B joined CNA A in the room and CNA B (who was the smaller CNA) grabbed my right hand, she pulled my thumb backwards and I screamed. Resident stated, the CNA's came around dinner time and they put me in the wheelchair that's when I noticed my right thumb and right wrist were swollen. Resident # 1 stated, My daughter told the staff to send me to the hospital. Interview on 09/03/2025 at 10:40 AM with Residents # 3 (Resident # 1's roommate). Resident # 3 stated, she was in the room and awake at the time of the incident and it was around 7 AM. Resident # 3 stated, There were 2 CNAs in the room that morning. She stated, the smaller one came in to help and that's when I heard a loud cry from (Resident # 1). and I couldn't see anything because the curtain was pulled closed but, I knew (Resident # 1) was in pain by the sound of her scream. Interview on 09/03/2025 at 10:50 AM with CNA C. CNA C he stated, I had cared for her (Resident #1) the week before on Thursday, August 14th, 2025, and Friday, August 15th, 2025 and she had no injuries then. He stated, on Monday, August 18th, 2025 (Resident # 1's) hand looked very different than last week, so I knew something was wrong. I immediately told the Nurse about (Resident # 1's) hand. He stated, A a Staff, Nurse came down to the room to see the resident's injury. He stated, They called Emergency Services came and took her to the hospital, and I didn't see her again until the next day. Interview on 09/03/2025 at 12:29 PM with Family member of Resident # 1. He stated, we had a recording of the morning of the incident, but we could not see the incident because the Aids pulled the curtain around the entire bed. He stated, all I could here is mother yelling and screaming and when they opened the curtain, you can see mom holding her hand. He stated, the family had put a screw on the curtain track to prevent the curtain from being pulled because the staff continued to try and hide from the camera. He stated his mom has dementia and that she doesn't remember details. During an interview with CNA A on 09/04/2025 at 12:35 PM revealed that CNA A said she was suspended due to Resident #1 having a bruise on her left thumb. CNA A said that she had not hurt Resident #1 or any other residents. She said she did not report the injury because it was CNA B who found the injury. She said Resident #1 did not complain of pain to her finger. Observation of Video on 09/03/2025 at 3:10 PM with.During an Interview with ADM and DON., ADM shared an approximate 5 minutes of video recorded on 08/17/2025 at 7:11 AM. The video reveals 2 CNA's entering Resident # 1's bed area. CNAs were identified by the ADM and the DON as CNA A (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676238 If continuation sheet Page 7 of 15 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 09/17/2025 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and CNA B. CNA A was observed pulling the curtain from the right side of the bed to the left side of Resident # 1's bed. The curtain served to block the view from the camera of the care being performed to Resident # 1. Per the audio of the video, Resident # 1 was heard to be shouting stop . Resident was also heard to scream loudly in a sharp, high pitch. When CNA A reopened the curtain, Resident #1 was observed to have on different clothing and Resident # 1 was positioned on her left side facing the window. CNA A and CNA B were observed to be holding soiled briefs and other soiled items. Observation shows both CNA's leaving the room and the video ended. During an interview with LVN A on 09/15/2025 at 12:36 PM revealed that on the day 08.17.2025 around lunch time, she was on the hallway when CNA B brought Resident #1 to LVN A at the nurse's station. CNA B told her, She noticed the resident was not able to use her hand to pick up her personal phone. She said CNA B also told her Resident # 1 could not use her hand properly. LVN A said that CNA B did not know how the injury to Resident #1 occurred. LVN A said she observed the resident's' right hand, and she saw a bruise on the upper part of the resident's right thumb. She said she asked Resident # 1, what happened? Resident # 1 said she did not know what happened and she did not remember. LVN A said she tried to assess the hand but Resident #1 would not let her touch it. Resident #1 said she was in pain. LVN A said that CNA B told her she did not know what caused the bruises to Resident #1. Record review of the Facility's Abuse, Neglect, and Exploitation, dated 11/2017, reflects: each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. It is also the policy of this Facility to recognize the resident right to personal privacy and confidentiality of their physical body, personal care, and personal space or accommodations. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This also includes the taking, keeping, using or distributing photographs or video recordings off residents in any manner that would demean or humiliate a resident, regardless of consent provided or the residents cognitive status. The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of the resident to be free from abuse, neglect, misappropriation of resident property, exploitation, or use of technology that would infringe on the residents right to personal privacy.The following Plan of Removal submitted by the facility was accepted on 09/16/2025 at 4:33 pm.Action: CNA A and CNA B Suspended pending investigation on 08/18/2025.Completion date 8/18/2025 CNA A and CNA B were terminated. Responsible: Director of Nurses/Designee Action: Skin Assessments conducted on all residentsStart Date: 8/19/2025Completion Date: 8/19/2025Responsible: DON/Designee Action: Medical Director, Nurse Practitioner and Physician Assistant notification of immediate jeopardy and plan of removal discussed. Start Date: 9/15/2025Completion Date: 9/15/2025Responsible: Executive Director Action: Ad hoc QA meeting. Attendees included ED, DON, Clinical Resource, Clusters Partners, Medical Director. Meeting included the Plan of Removal and interventions.Start Date: 9/15/2025Completion Date: 9/15/2025Responsible: Executive Director Action: Inservice Director of Nursing and Executive Director on Abuse and Neglect Policy Start Date: 9/15/2025Completion Date: 9/15/2025Responsible: Clinical Resource, MSN, Ed, DON Action: Inservice Director of Nursing and Executive Director on Resident Rights Start Date: 9/15/2025Completion Date: 9/15/2025Responsible: Clinical Resource, MSN/Ed, DON Action: Inservice initiated to all staff on Abuse and Neglect Policy to be conducted prior to start of next shift.Start Date: 9/15/2025Completion Date: 09/19/2025 Responsible: DONAction: Safe Surveys conducted on all residents.Start Date: 9/15/2025Completion Date: 9/15/2025Responsible: DON/Designee Action: Inservice of CNA A and CNA B on Abuse and Neglect with knowledge retention demonstrated with post-testStart Date: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676238 If continuation sheet Page 8 of 15 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 09/17/2025 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 9/15/2025Completion Date: 9/15/2025Responsible: DON/Designee Action: Inservice of CNA A and CNA B on Abuse and Neglect with knowledge retention demonstrated with post-testStart Date: 9/15/2025Completion Date: 9/15/2025Responsible: DON POR monitoring conducted on 9/16/2025 and 9/17/2025. Record review of IJ Binder on 9/16/2025 CNA A and CNA B have been terminated, and the termination is in the binder. Copies have been scanned. The Abuse Policy for Freedom from abuse, neglect, & exploitation, Residence, rights & responsibilities were in the binder. Verified that the email was sent to the ombudsman notifying them of the IJ. Verified that QAPI was done with the executive director, Director of Nursing, and clinical resources, and signed by each of them Residence safety surveys were completed In service on resident rights and abuse and neglect was given to the administrator in the DON by MSN/ED, RN clinical resources. In-service training completed by all staff on abuse and neglect, and resident rights. All staff or quiz on resident rights, abuse and neglect Staff contacted the resident #1s daughter to verify that they had notified her of the immediate jeopardy During an Interview with Resident #14 at 12:12 PM Resident # 14 Revealed he has never been injured by a staff member when he is getting care. Resident #14 said he has no concerns about the staff and that they treat him well. Resident #14 likes it at the facility. There were no other concerns at the time. During an interview with Resident #18 at 12:16 PM , He revealed he felt safe at the facility. Resident #18 said he has never been abused or injured by any staff at the facility. Resident #18 said that all the staff treat him well. Resident #18 said that he likes the care he is getting at the facility. During an interview with Resident #10 at 12:25 PM he revealed he feels safe at the facility. Said he has never been abused or injured by the staff. Resident #10 said that he likes the care that he is getting, and it is better than the care he was getting at the last facility. There were no other concerns at the time. During an interview on 09/17/2025 3:21 PM, ADM revealed per Abuse policy, suspected abuse should be reported immediately to him. If ADM is not available, staff member who could report it to ADON, DON, or management. LMS education portal before they start, and continuing education quizzes and refreshers. It was serviced yesterday. Has not witnessed any abuse in the facility. ADM said to prevent this from happening, he has staff get extra training and keep telling them about abuse. During an interview on 09/17/2025 3:04 PM, DON revealed, the facility is to use the provider letter when it is reportable and follow the 24-hour guidelines. All staff are required to notify the DON or the Nurse, and they will tell ADM. If there is an allegation pending investigation. Upon hire, reliance training it covers abuse and neglect. And that covers dementia care. All the training is annual. In-service on abuse yesterday, and before that was in August. Payday in-service for abuse. Has not witnessed abuse in the facility. More training on residents' rights and the right to refuse care and more training on that and cooperative residents. During an interview on 9-17-2025 at 2:15 PM RN said that if there is abuse, then is should be reported immediately. RN said abuse should be reported to the ADM or the DON. RN said that they get in-service training on abuse and neglect through videos, in person, and emails. The last in-services on abuse and neglect were 9-16-2025 and 9-16-2025. RN has not witnessed any abuse or neglect in the facility. During an interview on 09/17/2025 2:26 PM, CNA D said that if she sees abuse in the facility, then she is to report it immediately to the ADM, who is the abuse and neglect coordinator. CNA D has not witnessed abuse or neglect in the facility. CNA D said that she had in-service training on abuse and neglect, and the last time was 9-16-2025. CNA D said that she gets in-service training regularly for abuse and neglect. videos and meetings. CNA D has not witnessed abuse or neglect in the facility. During an interview on 09/17/2025 2:00 PM LVN B said if she sees abuse in the facility, she reports it immediately to the ADM, who is the abuse and neglect coordinator. LVN B said she has not witnessed any abuse in the facility. LVN B said that she gets (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676238 If continuation sheet Page 9 of 15 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 09/17/2025 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete in-service regularly on abuse. LVN B said the last time she had abuse training was 9-16-2025. LVN B said that get in-service training in person and videos. During an interview on 09/17/2025 2:06 PM, CNA 5 said she has not witnessed abuse or neglect in the facility. CNA 5 said if she sees abuse in the facility, then she tells the ADM. CNA 5 said the last time she had in-service training on abuse was on 9-16-2025. CNA 5 said she gets in-service training by video and in person. CNA 5 said that there is usually a test after. Training Monday, test Tuesday, and last week, and the video was at the beginning of the month. During an interview on 09/17/2025 2:00 PM, ADON revealed that abuse should be reported immediately to the ADM. If the ADM is not available, then it would be reported to the DON ADON stated that they he has received training on abuse regularly and the last time was on 9/16/2025. ADON stated he gets training in person, online, and they watch videos. To prevent abuse Human Resources does a background check on new employees. ADON said he has not witnessed any abuse or neglect in the facility. An IJ was identified on 09/15/2025. The Administrator was notified and an IJ Template was provided on 09/15/2025 at 5:55 p.m. While the Immediate Jeopardy was removed on 09/17/2025 at 4:33 pm, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Event ID: Facility ID: 676238 If continuation sheet Page 10 of 15 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 09/17/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources were reported immediately, but no later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse to the Administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 6 residents ( Resident # 1 reviewed for abuse and neglect. The facility failed to report to HHSC when Resident #1 was found to have a significant bruise and swelling to right thumb of unknown origin on 08/17/25 at 3:03PM. This failure to report could place the residents at risk for abuse. Findings included:Record review of Resident #1's admission Record, dated 09/03/25, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Unspecified Dementia, moderate (This is when symptoms become more severe, and the individual's ability to perform daily tasks declines significantly.), Hypertensive Heart (refers to heart conditions caused by high blood pressure.) and chronic kidney disease (Gradual loss of kidney function.).Record review of Resident #1's quarterly MDS Assessment, Section VCare Area Assessment summary dated 06/06/25, reflected her BIMS Score was 4 (indicates severe cognitive impairment, suggesting that the individual may require comprehensive assistance and specialized care approaches.).Record review of MDS, Section GG- Functional Abilities for Mobility Resident #1 needs Wheelchair.Record review of MDS, Section GG- Functional Abilities for self -care of Resident # 1 is 1(Dependent - Helper does ALL the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity.) Record review of Resident #1's care plan, revised 07/02/25, reflected: Focus: has Potential to demonstrate physical behaviors related to Dementia. Goal: Will not harm self or others through the review date. Interventions: Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Record Review of resident # 1's Weekly Skin Assessment on 08/15/2025 at 12:54 PM reflected L great toe abrasion and lateral ankle trauma wound present and no other skin issues noted. Record review for Change of condition for resident # 1's Skin Assessment on 08/17/2025 at 3:05 PM documents Bruise and swelling to right thumb. Record Review of Provider Investigation Report on 8/18/2025 reflects that Aid notified this nurse that upon getting resident up in her wheelchair, she noticed her right thumb was swollen and was unable to hold her phone while receiving a call from son. The Provider Investigation Report does not indicate how this injury occurred. The Provider Investigation Report stated incident occurred 08/17/25 at 11:50 AM and assessment was done on 08/17/2025 at 335 PM. The assessment reported Bruising and edema to right thumb. 08/18/2025 Resident # 1 was transferred at 10:30 AM offsite to St. [NAME]. Incident was reported by ED to Texas Health and Human Services complaint and Incident Intake via email on 08/19/2025 at 12:19 AM Interview & Observation of Resident # 1 on 09/03/2025 at 10:35 AM. Observed resident lying in bed, she raised her right hand and arm exposing a bruised on the lower right thumb. Resident stated 0n 08/17/2025 early in the morning she was awakened by CNA A. Resident #1 stated, I told them I wanted to sleep and I'll do it later. She stated CNA B joined CNA A in the room and CNA B (who was the smaller CNA) grabbed my right hand, she pulled my thumb backwards and I screamed. Resident stated, they came around dinner time, and they put me in the wheelchair that's when I noticed my right thumb and right wrist were swollen. Resident # 1's stated, my daughter told the staff to send me to the hospital. Interview on 09/03/2025 @ 10:40 AM with Resident # 2 (Resident # 1's roommate). Resident # 2 stated, she was in the room and awake at the time of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676238 If continuation sheet Page 11 of 15 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 09/17/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete incident and it was around 7 AM. Resident # 2 stated, there were 2 CNAs in the room that morning. She stated, the smaller one came in to help and that's when I heard a loud cry from Resident # 1 and I couldn't see anything because the curtain was pulled closed but, I knew Resident # 1 was in pain by the sound of her scream. Interview on 09/03/2025 @ 10:50 AM with CNA C. CNA C stated, I had cared for her the week before on Thursday and Friday and she had no injuries then. He stated, on Monday, Resident # 1's hand looked very different than last week, so I knew something was wrong. I immediately told the Nurse about Resident # 1's hand. He stated, A Staff, Nurse came down to the room to see the resident's injury. He stated, They called EMS and took her to the hospital, and I didn't see her again until the next day.Interview on 09/03/2025 at 12:29 PM with son of Resident # 1. He stated, we had a recording of the morning of the incident, but we could not see the incident because the Aids pull the curtain around the entire bed. He stated, all I could here is mother yelling and screaming and when they opened the curtain, you can see mom holding her hand. He stated, the family had put a screw on the curtain track to prevent the curtain from being pulled because the staff continued to try and hide from the camera. He stated his mom has dementia and that she doesn't remember details.Interview on 09/03/2025 @ 12:29PM with DON. She stated Resident # 1's son provided the video of the incident on 08/17/2025 but we could not see actual injury occurring, we just heard voices. Interview and observation of video on 09/03/2025 @ 1:15 PM. ED and DON provided a video recording of the incident on 08/17/2025. Video revealed CNA B rotated a privacy curtain all around the entire bed. Video did not reveal an incident of abuse. DON provided Police Report # Service request number 25-00281397.Call placed to [NAME] Policy Depart [PHONE NUMBER] was transferred to [PHONE NUMBER] Extension# 51038 requested copy of police report number 25-00281397. DON stated, both CNA's involved in this incident have been put on suspension.Record review of the Facility's Abuse, Neglect, and Exploitation, dated 11/2017, reflects: each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. It is also the policy of this Facility to recognize the resident right to personal privacy and confidentiality of their physical body, personal care, and personal space or accommodations. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This also includes the taking, keeping, using or distributing photographs or video recordings off residents in any manner that would demean or humiliate a resident, regardless of consent provided or the residents cognitive status. The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of the resident to be free from abuse, neglect, misappropriation of resident property, exploitation, or use of technology that would infringe on the residents right to personal privacy.and Abuse: Prevention of and Prohibition AgainstReporting reasonable suspicion of a crime against a resident in accordance with Section 1150B of the Social Security Act. Event ID: Facility ID: 676238 If continuation sheet Page 12 of 15 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 09/17/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure accurate resident identification before transport for outside medical appointments for 1 (Resident #10) of 3 sampled residents. The facility failed to ensure that Resident #10 made it to his scheduled surgical appointment, and the facility sent the wrong resident in his place. This finding could place residents at risk for missing medical treatments. Record review Resident #10's medical diagnosis shows that Resident #10is diagnosed with hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side (paralysis), heart failure, and major depressive disorder, recurrent moderate (depression). Resident #10 MDS showed that he had a BIMS of 10, which indicates moderate cognitive impairment. Resident #10.Interview on 9-17-2025 at 10:20 AM, an interview with Resident #10 said he did not make it to his cataract surgery, and he doesn't know what happened. Resident #10 told staff that he was scheduled to have an appointment. Resident #10 said that a CNA told him last night that the appointment was rescheduled. Resident #10 said he was going to have cataract surgery on his left eye. Resident #10 said that he had already had the surgery on his right eye. Resident #10 said that things happen, and he will have it done when it is rescheduled. Interview on 9-17-2025 at 12:16 PM, an interview with DR said that he has been doing this job for a couple of weeks. DR said that Resident #10 had the first appointment of the day. DR said that he pointed at a resident and asked a CNA on the floor if that was Resident #10. DR said he thought the CNA responded that was Resident #10, so DR said he then took that resident and not Resident #10 to the appointment. DR stated that ADON called him and told him he had the wrong resident. DR said that he took that resident back to the facility. DR said he is supposed to look at the face sheet before taking a resident to their appointments, and he did not. DR said he was in-serviced on resident identification the day it happened. DR said it could negatively impact a resident by a resident having a procedure that should not have happened. Interview on 9-17-2025 at 2:00 PM, with the ADON said he realized that the driver took the wrong resident to the appointment. ADOON said he called the DR to let him know that he had the wrong resident. ADON said the DR returned the resident to the facility. ADON stated that the DR is supposed to bring the face sheet with the resident's information to the room to verify that it was the resident he was supposed to take to the appointment. On 9-17-2025 at 3:04 PM, an interview with the DON said that DR is supposed to have the face sheet of the resident when they are being taken to appointments. DON said the DR should check in PCC and check with the floor nurse. The DR is trained to get on PCC to verify the resident. DON said the DR asked the CNA in the hall if that was Resident #10, and the DR said that he thought the CNA told him it was Resident #10. DON said that DR should be asking a nurse on the floor if they have the right resident, along with having the face sheet to verify he has the right resident. DON said that Resident #10 could have missed an important surgery. DON said that the procedure was rescheduled. On 9-17-2025 at 2:00 PM an interview with the ADM said that DR should verify which resident they have with the face sheet to make sure he has the right resident. ADM said that staff are trained on PCC and should know where to find the resident's Face sheet. ADM said the ADON is the one who discovered that the wrong resident was taken and called DR. ADM said that the DR will now be checking with the nurse in the hall to verify. ADM said the resident could have had the wrong procedure. ADM said the DR was counseled and trained on making sure he has the right resident. The facility did not have a written Policy on what the driver was supposed to do when verifying they have the correct resident when taking residents to outside doctors' appointments. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676238 If continuation sheet Page 13 of 15 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 09/17/2025 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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 maintain an effective pest control program so that facility was free of pests and rodents for 1 of 7 bedrooms reviewed for physical environment. The facility failed to ensure that Resident #2's bedroom was free from ants. This finding could place residents at risk for bug bites, unsanitary environment and emotional distress. RR of Resident #2's face sheet revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #2 had diagnoses of Parkinson's Disease, Chronic Kidney Disease, and Muscle Weakness. RR of Resident #2's care plan dated 06/08/2023 revealed Resident #2 was at risk for impaired communication function/dementia r/t short term memory loss. RR of Resident #2's hospital record dated 08/14/2025 which triggered a visit for infected insect bite or sting. The record indicated a prescription for Cephalexin 500 MG CAP oral every 6 hours 10 days and Loratadine 10 MG tab oral daily. An observation was conducted on 09/03/2025 at 3:09PM in Resident #2's bedroom. It was observed in the room that an ant was observed. An interview was conducted on 09/03/2025 at 3:09PM with Resident #2. Resident #2 reported that a couple of weeks ago in his bedroom there were some ants crawling from the frame of the door. Resident #2 stated he touched the ants and then went to bed. Resident #2 said about 2-3 hours later, he started feeling sharp points on the sides of his body. He stated that he believed he got bites from the ants. He stated that they were still there, and the facility was aware of it. Resident #2 stated that he believed his room was the only area affected by the ants. Resident #2 stated that the facility has had pest control come and spray for the ants, but the system does not work. Resident #2 stated that the ants bother him as well as make him uncomfortable and itchy. An interview was conducted on 09/04/2025 at 2:50PM with the MD revealed MD had been employed at the facility for 7 years. The MD stated he had received training on resident rights which included the residents had the right to decline services they provide, right to their privacy and right to have their own stuff. The MD stated he received training on pest control. The MD stated that there was an issue with ants in the facility while he was on vacation and when he returned, he heavily treated the area with pest control services. The MD stated the policy for pests in the facility was to report it if they were observed in the facility. The MD stated that pest control services come out at least 2 time a month in the summer times. The MD stated that the main manager was in charge of pest control services. The MD stated a negative effect of having bugs and insects in the facility was that residents would have a low quality of life. The MD stated that he believes ants were in the facility because of the weather. The MD confirmed that there were complaints about ants in the facility in Resident #2's bedroom. An interview was conducted on 09/04/2025 at 3:10PM with the DON, the DON said she had received trainings on Resident Rights which included the right to make decisions. The DON stated that she had received training for pest control services which included how to identify and prevent bugs from coming into the facility. The DON stated the expectation for identifying bugs in the facility was if staff sees any ants, they should log it into the pest control book located at the nurse's station. The DON stated the MD will receive these notifications. The DON stated pest control services come out 2x a month and as needed. The DON stated that the MD was in charge of pest control services and bug prevention. The DON stated a negative affect it could have on residents if there were bugs and insects in the facility was the potential for residents to be bit or live in fear. An interview was conducted on 09/04/2025 at 4:30PM with the ADM who reported working at the facility for 2.5 years. The ADM stated he had received training for resident rights which included that the facility was the resident's home. The ADM stated that the MD was in charge of pest control services but that the whole facility was a team, who Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676238 If continuation sheet Page 14 of 15 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 09/17/2025 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete all have to help, if they see something they need to report it. The ADM stated that pest control services come out every other week. The ADM stated that the resident had spots on his body, and they sent him to the ER to be checked for infectious diseases such as smallpox. The ADM stated that the resident #2 had bites/spots on his body and was unsure where it came from. The ADM stated he had not seen any ants in the facility. RR of an undated document provided by the facility titled Pest Control the following information was included in the document:1. It is the policy of this facility to utilize pesticides and rodenticides in a safe and efficient manner to control pests with the least amount of contamination to the environment.2. When pests are sighted, determine why the infestation is occurring and advise department head on preventive measures.3. Report insect or pest sightings to the housekeeping/maintenance supervisor immediately. Event ID: Facility ID: 676238 If continuation sheet Page 15 of 15