Inspection visit

Health inspectionJune 30, 2023

Q: What happened during the June 30, 2023 survey of Legend Oaks Healthcare and Rehabilitation-Kyle?

This was a inspection survey of Legend Oaks Healthcare and Rehabilitation-Kyle on June 30, 2023. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Q: Were any deficiencies cited at Legend Oaks Healthcare and Rehabilitation-Kyle on June 30, 2023?

Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."

Q: What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

Legend Oaks Healthcare and Rehabilitation-KyleCMS #6762728 citations on this visit

8 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Residents have the right to formulate an advance directive for 1 of 18 resident (Resident #31) reviewed for advanced directive in that: The facility failed to have the physician's signature and license number recorded on the Out of Hospital Do Not Resuscitate (OOHDNR) order, which made the advanced directive invalid. This failure could affect any resident in the facility who had an OOHDNR in their chart and place them at risk of having cardiopulmonary resuscitation (CPR) performed against their wishes. Findings: Record review of Resident #31's face sheet dated [DATE] revealed an admission on [DATE] with diagnoses which include: Alzheimer's disease; Chronic Kidney Disease, (stage 4); dementia unspecified without behavioral disturbance, psychosis or anxiety; osteoarthritis (cartilage deterioration between the bones) and hypothyroidism (when body does not create and release enough thyroid hormone in body). Record review of Resident #31's Quarterly MDS assessment, dated [DATE], indicated a BIMS of 15, which revealed the resident was cognitively intact. Record review of Resident #31's Care Plan, most recently updated on [DATE] revealed code status of DNR (no CPR). Record review of Resident #31's active Physician Order Summary Report revealed an active order for DNR as of [DATE]. Record review of Resident #31's OOH-DNR, dated [DATE], revealed the physician's signature and medical license number were missing from the form. During an interview with the SW on [DATE] at 11:34 a.m. the SW stated, Resident #31's DNR, must have been missed in her most recent audit. The SW said, it is not valid and if she were to code she could be considered full code which would mean she would get CPR, her wishes would not be honored as requested. The SW stated she was responsible for ensuring DNR's are completed at the facility. During an interview and record review with the DON on [DATE] at 11:58 a.m., the DON stated, The social worker is responsible for helping with the DNR's but the nurses have to do them sometimes. The DON further stated, I do not see the physician's signature, the license number should be on there as (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 14 Event ID: 676272 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 676272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation-Kyle 1640 Fairway Kyle, TX 78640 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 0578 well, but we go by the orders the physician signs not by the DNR. Level of Harm - Minimal harm or potential for actual harm Record review of the Texas Health and Human Services webpage titled, Out of Hospital Do Not Resuscitate Program, updated 12/2020, accessed [DATE] revealed, Out-of-Hospital Do-Not-Resuscitate Form section D requires the patient's attending physician to sign and date the form, print or type his/her name and give his/her license number. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676272 If continuation sheet Page 2 of 14 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 676272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation-Kyle 1640 Fairway Kyle, TX 78640 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 of 2 residents reviewed for quality of care (Resident #316). Residents Affected - Few The facility did not maintain physician orders and medical information needed to monitor Resident #316's cardiac pacemaker (electronic device that is implanted in the body to monitor heart rate and rhythm that stimulates the heart with electrical impulses to maintain or restore a normal heartbeat) parameters for proper functioning. This failure could place residents of risk for not receiving proper care and treatment. The findings included: Record review of Resident #316's face sheet, dated 06/28/23 revealed a [AGE] year-old male admitted [DATE] with diagnoses of; Fracture of shaft of right Fibula, Type 2 Diabetes, Hypertension (high blood pressure), Paroxysmal Atrial Fibrillation (rapid, erratic heart rate), Presence of Cardiac Pacemaker. Record review of Resident #316's admission MDS, dated [DATE] revealed MDS had not been completed because Resident #316 was admitted on [DATE]. Record review of Resident #316's Care Plan, dated 05/19/23 revealed care plan did not address the pacemaker. Record review of Resident #316's most recent admission Initial admission assessment, dated 05/31/23 revealed Pacemaker frequency unknown. Per resident, this is pacemaker number 4. It is managed by [agency]. Record review of Resident #316's Order Summary Report, dated 06/28/23 did not have orders for the pacemaker or parameters. Record review of Resident # 316's Cardiologist Clinical Summary Report, dated 05/02/23 revealed Pacemaker .Has 4 and a half years left on the battery. During an interview and observation on 06/27/23 at 10:46 AM Resident #316 stated he had the pacemaker for years. Observed defibrillator site to left chest. During an interview and record review on 06/29/23 at 12:17 PM with ADON, she reviewed Resident #316's medical diagnosis, orders and care plan and verified that the pacemaker was diagnosed but had no orders and was not care planned. She stated, The pacemaker was supposed to be monitored every shift. During an interview on 06/29/23 at 12:47 PM with DON, when asked why one resident's pacemaker was monitored and the other resident's pacemaker was not monitored, the DON stated, They have different doctors. During an interview on 06/30/23 at 11:06 AM, the DON and Administrator stated the Policy/Procedure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676272 If continuation sheet Page 3 of 14 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 676272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation-Kyle 1640 Fairway Kyle, TX 78640 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 regarding Pacemaker care/monitoring was not available. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676272 If continuation sheet Page 4 of 14 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 676272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation-Kyle 1640 Fairway Kyle, TX 78640 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 2 residents (Resident #87) reviewed for dialysis in that: Residents Affected - Few The facility did not maintain communication, coordination and collaboration with the dialysis facility for Resident #87. This deficient practice could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs. The findings were: Record review of Resident #87's face sheet, dated 06/29/23 revealed a [AGE] year old female admitted on [DATE] and re-admitted on [DATE] with diagnoses that included end stage renal disease (condition in which the kidneys cease functioning on a permanent basis), and dependence on renal dialysis. Record review of Resident #87's most recent quarterly MDS assessment, dated 05/05/23 revealed the resident had a BIMS score of 15 meaning she was cognitively intact for daily decision-making skills and the MDS indicated she required dialysis treatments. Record review of Resident #87's Order Summary Report, dated 5/18/23 revealed an order for the following: -Hemodialysis 3 x week every Monday, Wednesday and Friday with order date 06/05/23 and no end date -Dialysis communication form to be completed and filed/scanned in chart on dialysis days every shift every [NAME], Wed, Fri with order date of 01/04/23. Record review of the facility Nursing Dialysis Communication Record revealed 3 sections on the form with the following instructions: The first section indicated FACILITY NURSES were to complete the information along with any special instructions or information; the second section indicated: DIALYSIS NURSES were to complete the section which included pre and post treatment weights, access problems, change in condition and special instructions or information; and the third section indicated FACILITY NURSES/POST DIALYSIS which included information about the dressing, any bleeding, vital signs and any special instructions or information. Record review of Resident #87's Nursing Dialysis Communication Record, dated 06/02/23 and 06/19/23 revealed the forms were incomplete. These forms were found in the Dialysis Communication Notebook which the resident kept in the back of her wheelchair. Review of dialysis communication sheets revealed that facility completed the top portion of form prior to dialysis but the sheets were blank for dialysis communication and post dialysis for facility. Dates reviewed: 6/19/23; 6/16/23; 6/12/23; 6/5/23; 6/2/23; 5/29/23; 5/26/23; 5/24/23; - there were also sheets made out for 6/23 and 6/26 but a nurses note indicated that resident refused to go to dialysis on those days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676272 If continuation sheet Page 5 of 14 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 676272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation-Kyle 1640 Fairway Kyle, TX 78640 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 06/29/23 at 11:13 AM, an interview with LVN B revealed Resident #87 preferred to keep the dialysis book in her room so it was not available at the nurses station. LVN B also stated that Resident #87 frequently refused to go to dialysis so she had missed several appointments. On 06/29/23 at 03:30 PM, the DON was asked to review the dialysis sheets in Resident #87's notebook. The DON stated, This was for communication with dialysis. If they have any issues, they just call us. I've talked with the Dialysis Manager, and he said he would talk with his nurses. The return information makes sure she was okay. There could be a drop in BP (blood pressure) afterwards. If there are any significant changes, we communicate with dialysis. We usually just call them. If there was a major change in condition such as refusing to go, we will see if the NP (Nurse Practitioner) saw her. Nurses just check on residents when they return from dialysis - BP was not required. She has a permacath (a special IV line in the external jugular vein in neck for hemodialysis) so dialysis takes care of that. Resident should not be keeping the book. The DON stated she was not aware that the resident was keeping her book. The DON said she will talk with Resident #87 about this. The DON also provided the policy for dialysis but it did not contain information about the completion of the dialysis forms. During an interview on 06/30/23 at 09:56 AM with LVN C, nurse was asked about the completion of the dialysis forms. LVN C stated We check her BP and make sure she is stable. We check her before and after she goes. She has a binder with the forms. When she comes back she gives me the binder. I have noticed that sometimes they don't fill out the form - sometimes she says they do check her but the form wasn't filled out. LVN C stated the purpose of the forms was to monitor her vitals and make sure she was okay. Resident #87 said she was going to dialysis today. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676272 If continuation sheet Page 6 of 14 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 676272 B. Wing (X3) DATE SURVEY COMPLETED A. Building 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation-Kyle 1640 Fairway Kyle, TX 78640 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services to ensure accurate administration and documentation of medications for 1 of 12 residents (Resident #85) reviewed for pharmacy services and medication administration in that: The facility failed to record blood pressure and heart rate as required for Resident #85. This failure placed residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. The findings included: Record review of the admission face sheet, dated 6/30/2023, reflected Resident #85 was a [AGE] year-old male admitted on [DATE] with a diagnosis included: unspecified atrial fibrillation (irregular heartbeat) and hypothyroidism, unspecified (underactive thyroid). Record review of the care plan with a start date of 4/10/2022, reflected Resident #85 had a problem area of risk for diuresis (a dangerous level of urine within the body) related to heart failure with associated intervention of: administer medications as ordered. Record review of physician's orders reflected Resident #85 had the following order: Metoprolol Tartrate Tablet 25 MG, Give 1 tablet by mouth two times a day for atrial fib hold for SBP < 100 HR <60 with the start date of 12/22/2022. Record review of the MAR for Resident #85 from 6/1/2023 to 6/28/2023, reflected missed heart rate and blood pressure readings prior to administering Metoprolol on: *6/6/2023 3:00 PM to 5:00 PM: [blank space, no reason code documented]; *6/7/2023 3:00 PM to 5:00 PM: [blank space, no reason code documented]; *6/8/2023 5:00 AM to 7:00 AM: [blank space, no reason code documented]; *6/9/2023 5:00 AM to 7:00 AM & 3:00 PM to 5:00 PM: [blank space, no reason code documented]; *6/13/2023 3:00 PM to 5:00 PM: [blank space, no reason code documented]; *6/14/2023 3:00 PM to 5:00 PM: [blank space, no reason code documented]; *6/16/2023 3:00 PM to 5:00 PM: [blank space, no reason code documented]; *6/17/2023 3:00 PM to 5:00 PM: [blank space, no reason code documented]; *6/18/2023 5:00 AM to 7:00 AM: [blank space, no reason code documented]; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676272 If continuation sheet Page 7 of 14 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 676272 B. Wing (X3) DATE SURVEY COMPLETED A. Building 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation-Kyle 1640 Fairway Kyle, TX 78640 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 0755 *6/19/2023 3:00 PM to 5:00 PM: [blank space, no reason code documented]; Level of Harm - Minimal harm or potential for actual harm *6/20/2023 3:00 PM to 5:00 PM: [blank space, no reason code documented]; *6/24/2023 3:00 PM to 5:00 PM: [blank space, no reason code documented]; Residents Affected - Some *6/25/2023 5:00 AM to 7:00 AM & 3:00 PM to 5:00 PM: [blank space, no reason code documented]; *6/26/2023 5:00 AM to 7:00 AM: [blank space, no reason code documented] Interview on 6/29/2023 at 11:11 AM, ADON A stated she investigated the instances of missing HR and BP monitoring for Resident #85 and concluded that staff were still administering the medication based on the parameters but were not documenting the BP and HR within the EHR. The ADON stated the risk associated with this practice was that nursing administrations were not able to determine whether BP and HR were truly collected to be able administer medications with required parameters during a medication audit. Interview on 6/30/2023 at 3:45 PM, the DON stated the expectation was the nursing staff administer medications with parameter set to first evaluate the vital signs and then document the vital signs as they could be used to see trends but also to determine if the resident was eligible for the dose. The DON stated the risk associated was that the resident might receive a medication that they should not if the nurse or med aide did not check their heart rate or blood pressure first. Review of Administering Oral Medications policy, undated, reflected the following step in the preparation stage: Determine if parameters were set before administering the medication; if so, collect measurements to evaluate if eligible for dose. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676272 If continuation sheet Page 8 of 14 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 676272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation-Kyle 1640 Fairway Kyle, TX 78640 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure residents were given psychotropic medications to treat specific diagnoses for 1 of 1 Residents, Resident (#74) reviewed for unnecessary psychotropic medications. The facility failed to ensure the medication Aripiprazole (Abilify) was given to treat a specific diagnosis for Resident #74. This failure could affect residents who received psychotropics in the facility and put them at risk for adverse consequences such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. The findings were: Record review of Resident #74's face sheet dated 6/30/2023 reflected a [AGE] year-old female with an admission date of 6/19/2021 with a primary diagnosis of major depressive disorder, single episode, unspecified. Record review of Resident #74's physician orders, dated 6/30/2023 reflected an order for Aripiprazole (an antipsychotic medication used to treat schizophrenia, bipolar disorder, depression, and Tourette syndrome. It can also treat irritability associated with autism.) Abilify Oral Tablet 10 MG (Aripiprazole) Give 1 tablet by mouth one time a day for delusional disorder/depression and an order date 5/26/2023. Interview on 6/30/2023 at 11:11 AM, ADON A stated Resident #74's EHR active diagnoses page did not reflect a current diagnosis of delusional disorder or related delusion diagnosis and the medication was inputted by the nurse practitioner and confirmed by ADON A. ADON A stated Resident #74 was diagnosed with delusional disorder by psychiatric services on 5/25/2023 and that MDS Coordinator A would update the active diagnoses during the next quarterly assessment. ADON A stated she did not believe the failure to assign a specific diagnosis for the medication to be of harm to the resident as it was purely documentary. Interview on 6/30/2023 at 1:29 PM, MDS Coordinator A stated she updated Resident #74's current diagnoses during the last quarterly assessment and would add the diagnosis of delusional disorder during the next quarterly assessment. MDS Coordinator A stated her role responsibility does not include updating pharmacy orders to reflect specific diagnoses as that was the floor nurse's job. Interview on 6/30/2023 at 3:45 PM, the DON stated the expectation was that all psychotropic medications have specific diagnoses within the EHR, and that direct care staff update the EHR to reflect updates as they are revealed and added. The DON stated she did not believe the failure to have more than minimum harm to the resident as Resident #74 did have depression, but her EHR did not currently reflect a diagnosis of delusional disorder. The facility could not provide a copy of the policy for unnecessary medications related to documenting antipsychotics. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676272 If continuation sheet Page 9 of 14 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 676272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation-Kyle 1640 Fairway Kyle, TX 78640 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure food was prepared in a form designed to meet the residents needs for 1 of 3 residents (Resident #31) reviewed for mechanical soft diet, in that: Resident #31 was provided a whole biscuit cooked hard on the bottom. This failure could place the resident who had physician orders for a mechanical soft diet at risk for choking. The findings included: Record review of Resident #31's face sheet dated 06/29/2023 revealed an admission on [DATE] with diagnoses which included: Alzheimer's disease; Chronic Kidney Disease, (stage 4); dementia unspecified without behavioral disturbance, psychosis or anxiety; osteoarthritis (cartilage deterioration between the bones) and hypothyroidism (when body does not create and release enough thyroid hormone in body). Record review of Resident #31's Quarterly MDS assessment, dated 05/10/2023, indicated a BIMS of 15, which revealed the resident was cognitively intact. Record review of Resident #31's most recent Physician Order Summary, printed on 06/29/2023 revealed REGULAR diet MECHANICAL SOFT texture, THIN LIQUIDS consistency, house shakes with meals. Record review of Resident #31's active Care Plan, with a print date of 06/29/2023 revealed the resident was being monitored for malnutrition, muscle wasting and weight loss. The care plan indicated the resident was to be served a regular diet, mechanical soft texture, thin liquids, 2 health shakes with meals. Record review of the Resident's meal card served with the meal containing the biscuit, dated 06/28/23, revealed Resident #31 was to receive a mechanical soft texture During an observation and interview with Resident #31 on 06/28/2023 at 9:00 a.m., in the resident's room, revealed the resident was served a biscuit the resident identified as being hard. Resident #31 handed the biscuit to this surveyor and said, this biscuit is too hard, I don't have any teeth and I can't eat it. Resident #31 further stated, sometimes I have to return them back, they should not give us hard biscuits. During an interview with RN G on 06/28/2023 at 9:19 a.m. she explained Resident #31 was supposed to be served mechanical soft meals. She said she verified the breakfast trays on 06/28/2023, she further stated biscuits are mechanical soft and that nurses do not touch the food explaining she would not have known if the biscuit was hard on the bottom. During an Interview with the DM on 06/28/2023 at 9:19 a.m. the DM explained Resident #31 should have not received a biscuit without gravy. The DM stated the biscuit should have been split in half and served with gravy on top since Resident #31 was supposed to be served a mechanical soft diet texture. She further stated, the resident could have choked on that biscuit, I did not know how it was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676272 If continuation sheet Page 10 of 14 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 676272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation-Kyle 1640 Fairway Kyle, TX 78640 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 0805 supposed to be until the regional staff told me this morning. Level of Harm - Minimal harm or potential for actual harm During an Interview and Observation with the Administrator on 06/28/2023 at 9:25 a.m., the Administrator said, Mechanical soft should not be like that, after he looked at the biscuit from Resident #31's tray, that looks like a regular biscuit. He further stated he was not sure exactly what mechanical soft should look like but the nurses are supposed to verify the trays before they are served. Residents Affected - Few No policy related to diet textures was provided prior to exit, by the DS, DM or the Administrator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676272 If continuation sheet Page 11 of 14 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 676272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation-Kyle 1640 Fairway Kyle, TX 78640 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. Residents Affected - Some The facility failed to ensure food items in the walk-in refrigerator/freezer and dry storage were dated and labeled. These failures could affect Residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: 1. One unlabeled and undated large clear plastic bag of a substance identified as possibly being meat by the DS, in the walk-in freezer. 2. One carton of expired thickened liquids dated in the dry storage area. 3. One large clear plastic bag, identified by the DS as corn flakes opened and not sealed. An observation and interview with the DS on 06/27/23 at 10:22 a.m. the walk-in freezer revealed an unlabeled/undated large clear plastic bag containing an unknown substance. The DS said she nor any of the staff knew where the unidentified/unlabeled plastic bag came from or why it was in the freezer. The DS further stated she believed it might be possibly some type of meat but that all items in the freezer should be labeled and dated to ensure all residents receive good food. An observation and interview with the DS on 06/27/23 at 10:30 a.m. in the dry storage area with the DS revealed one carton of expired thickened liquids and an opened and unsealed bag of what she identified as corn flakes. The DS said, the liquid should not be used if the date has passed because it is not good. The DS further stated the items in the dry storage area are supposed to be closed and dated when they are opened. During an interview with the DM on 06/29/23 at 11:07 a.m. the DM said, all items in the refrigerators, freezers and dry storage areas are supposed to be closed shut, labeled and dated. The DM said, all staff has been in-serviced and are supposed to make sure those things happen to take care of the residents. During an interview with the Administrator on 06/29/23 at 1:01 p.m., the Administrator explained he was unaware there were any expired food items in the kitchen. Review of The U.S. Public Health Service, Food Code, dated 2017 revealed the following: (A) Food Packaged in a Food Establishment, shall be labeled as specified in Law, including 21 CFR 101-Food labeling, and 9CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676272 If continuation sheet Page 12 of 14 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 676272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation-Kyle 1640 Fairway Kyle, TX 78640 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 0812 (1) The common name of the Food, or absent common name, an adequately descriptive identity statement Level of Harm - Minimal harm or potential for actual harm The Facility Food Storage Policy provided by the DM and the Administrator did not reveal any direction on labeling of any items in refrigerators, freezers or dry storage areas. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676272 If continuation sheet Page 13 of 14 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 676272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation-Kyle 1640 Fairway Kyle, TX 78640 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly, for 1 of 2 dumpsters in that: Residents Affected - Few Dumpster #1 had one half of the top lid open with garbage items visible and on the ground outside the dumpster. This deficient practice could place residents who reside at the facility at risk of unsanitary conditions that could result in the attraction of vermin and rodents and expose them to germs and diseases carried by vermin and rodents. The findings were: Observation on 06/28/23 at 1:35 p.m. revealed Dumpster #1 had an open lid and several latex gloves beside and in front of the dumpster on the ground. Observation on 06/29/23 at 6:11 p.m. revealed Dumpster #1 had an open lid and several latex gloves beside and in front of the dumpster on the ground, in addition to a disposable razor on the ground beside the dumpster. Observation on 06/30/23 at 8:49 a.m. revealed Dumpster #1 had the lid open with garbage exposed, in addition to latex gloves, plastic debris and a disposable razor on the ground next to the dumpster. During an Interview with the DM on 06/30/23 at 3:08 p.m. the DM said there should not be any trash items on the ground around the dumpsters, she said she was not aware there was any rule that states the dumpster lids should be closed. However, she did see the dumpster lid open and trash on the ground in front of the dumpster today. During an Interview with Administrator on 06/30/23 at 3:52 p.m., the Administrator stated the facility did not have a policy regarding trash or garbage storage outside. The Administrator did not identify a responsible staff person for the task but did state all trash should go in the trash can for infection control purposes. Review of the 2017 U.S. Public Health Service, Food Code revealed the following: Section 5-501.113 Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (B) With tight-fitting lids or doors if kept outside the FOOD Establishment. Section 5-501.114: Using Drain Plugs. Drains in receptacles and waste handling units for REFUSE, recyclables, and returnables shall have drain plugs in place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676272 If continuation sheet Page 14 of 14

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Citations

8 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0578GeneralS&S Dpotential for harm
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
0698GeneralS&S Dpotential for harm
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
0755GeneralS&S Epotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
0805GeneralS&S Dpotential for harm
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
0814GeneralS&S Dpotential for harm
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

FAQ · About this visit

Common questions about this visit

What happened during the June 30, 2023 survey of Legend Oaks Healthcare and Rehabilitation-Kyle?

This was a inspection survey of Legend Oaks Healthcare and Rehabilitation-Kyle on June 30, 2023. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Legend Oaks Healthcare and Rehabilitation-Kyle on June 30, 2023?

Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·June 30, 2023