Health inspection·August 10, 2023

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #1's MDS, dated [DATE] revealed, Section C (BIMS) and Section N (Medications) were not completed. Record review of Resident #1's Physician Order dated 08/02/23 stated: Chlorpromazine HCl Oral Tablet 10 MG (Chlorpromazine HCl): Give 1 tablet by mouth one time a day for Agitation/PTSD. Order Date and D/C date were 08/02/2023 and 08/07/2023 respectively. Record review of Resident #1's MAR of August 2023 revealed that Chlorpromazine HCl Oral Tablet 10 MG was administered on 08/03/23,08/04/23, 08/05/23, 08/06/23 and 08/07/23. Record review of Resident #1's consent form revealed, Resident #1 had PTSD and was based on review of available medical records. The consent form was created on 08/02/23 and signed by the resident on 08/08/23 (after the discontinuation of Chlorpromazine HCl on 08/07/23). In a telephone interview on 08/10/23 at 12:00 PM the FM stated she was an RN by profession and on 08/07/23 when she was going through Resident #1's MAR, she had noticed Resident#1 was administered with Chlorpromazine HCl Oral Tablet 10 MG once a day. The start date for this medication was 08/02/23 and was for Agitation/PTSD. FM stated Resident # 1 never diagnosed with PTSD or any other mental illness at any point of time in his life. She said she requested the NP to stop giving this unnecessary medication to him and NP discontinued the medication on 08/07/23 with immediate effect. FM said, at the hospital, Resident #1 was prescribed for Chlorpromazine for hiccough (A characteristic sound like that of a cough due to the spasm of the diaphragm) that he had developed after the surgery, and it was resolved before admitting to the facility. FM said no one from the facility explained to the resident or family about the rationale for administering this medication at the facility for agitation/PTSD. She stated, had they discussed this with family and/or resident, this mistake could have been avoided. In a telephone interview on 08/10/23 at 3:00PM Resident #1 stated he never had any kind of mental illness. Resident #1 said, on the admission day LVN A asked him if he had any mental illness since he had an antipsychotic medication in the list. Resident #1 reported, when he stated he was not diagnosed with any mental illness, LVN A stated he had to take a medication for some kind of mental illness since it was ordered by the NP (Resident was unable to name the medication as Chlorpromazine). When investigator asked him, if LVN A explained about the effect and side effect of the medication and what mental illness the medication was for, Resident #1 stated she did not. Resident #1 stated he would not have agreed to take that medication if he knew that it was for managing agitation since he was not an angry man. He stated, 3 days before the FM identified this mistake and made aware to the people at the facility. In a telephone interview on 08/10/23 at 2:00 PM. the NP stated she discontinued Chlorpromazine on 08/07/23 on FM's request. When the investigator asked NP why Chlorpromazine was prescribed, NP stated since it was given at the hospital and was listed in the discharge summary as home medication, she guessed Resident #1 might have some kind of mental illness. When the investigator asked, since there was no information regarding Resident #1 having any mental illness, had she discussed about the diagnosis and effect and side effect of Chlorpromazine to the resident or his family and received a consent before commencing the medication, she stated she did not as the consent forms were completed by the nurses. When the investigator asked, what would have been the appropriate action, NP stated, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676272 If continuation sheet Page 2 of 11 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 08/10/2023 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 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some before placing the order for Chlorpromazine she should have discussed and confirmed about it, with the hospital clinical staff, Resident #1, or FM, why it was administered at the hospital and the rationale for listing it among the home medicines. During an interview and record review on 08/10/23 at 3:30PM LVN A stated that she was the nurse who went to get the consent for Chlorpromazine. LVN A stated, when she stated he had mental illness and there was a medication prescribed for that, Resident #1 reported to her that he never had a diagnosis of any mental illness. LVN A said, when she stated Chlorpromazine, an antipsychotic medication was there in the discharge medication list from the hospital, Resident #1 agreed to sign a consent form, stating there must be some reason then. LVN A showed a consent form that was dated 08/02/23 and signed by resident on the same day. Review of this form revealed, the consent form did not have the information about the diagnosis, diagnostic criteria, name of the medication, probable clinically significant side effect of the medication and need and benefit of the medication. When investigator asked LVN A, if she explained to Resident #1 about the basis of the diagnostic criteria, the medication and clinically significant side effects of the medication, LVN A stated she did not as it had to be done later by the NP who prescribed the medication. In a telephone interview on 08/10/23 at 2:00 PM, the MD stated administration of Chlorpromazine at a lower dose was not harmful to Resident #1 since he was taking it at the hospital and at the facility, it was the continuation of it. When investigator asked, if diagnosing mental illness based on guess work was appropriate, he stated continuing the psychotropic medication irrespective of diagnosis was the right decision since stopping psychotropic medication suddenly have consequences to the safety of residents. When the investigator asked about the appropriateness of administering psychotropic medications without proper explanation and consent, MD stated since it was the continuation of the medication that he was receiving at the hospital, Resident #1 might be aware of it. He added, it was not reasonable to delay the order of psychotropic medications that residents were already receiving in the community, for a reason of obtaining informed consent. In an interview on 07/10/2023 at 4:30 PM, the DON stated, there was a consent form created by the NP and signed by Resident #1. She said the consent had all the component like diagnosis, explanation of possible side effect. When investigator pointed out that the resident had no diagnosis of PTSD in any records, DON stated since Chlorpromazine was ordered for a wrong diagnosis, the medication was unnecessary, and the expectation was no unnecessary medication would be administered to any residents. She stated, the confusion occurred because the medication listed as home medication in the discharge summary from ASW hospital however diagnosis without accurate information was not the best practice. When investigator stated that Resident #1 signed the consent on 08/08/23, DON said though it was signed after the discontinuation of the medication, there was a possibility that the nurses or NP explained about the effect and side effect of the medication while he was taking the medication. Record review of the facility's policy revised on 01/2022, titled Resident Rights reflected: It is the policy of this facility to inform the resident both orally and in writing of his/her rights as a resident, as well as the rules and regulations governing the resident's conduct and responsibilities during his/her stay in the facility . .4. The facility will inform the resident of his/her rights and responsibilities in a language that is both clear and understandable to the resident. Should the resident's knowledge of English be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676272 If continuation sheet Page 3 of 11 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 08/10/2023 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 0552 inadequate for understanding such rights and responsibilities, his/her rights and responsibilities will be explained in the language that is familiar to the resident Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676272 If continuation sheet Page 4 of 11 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 08/10/2023 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 the services provided by the facility meet professional standards of quality for 1 of 5 residents (Resident # 1) reviewed for professional standards in that: Residents Affected - Some -The facility failed to ensure Resident #1 was not diagnosed without subjective or objectives evidences and based on assumptions and judgements, that leads to administering unnecessary psychotropic medication. This failure placed residents at risk of receiving unnecessary psychotropic medications which could result in decline in health status. The findings include: Record review of Resident #1's face sheet, dated 08/10//2023, revealed a [AGE] year-old male whose admission to the facility was 08/02/2023. The resident had diagnoses of Cellulitis(Bacterial infection) of right toe, Osteomyelitis (inflammation or swelling of bone tissue ), right ankle and foot, Hypertension, Chronic Kidney Disease, Atherosclerotic heart disease( thickening or hardening of the arteries) of native coronary artery9 Artery of the heart) without angina pectoris(Chest pain), Type 2 diabetes mellitus with diabetic nephropathy(the deterioration of kidney function.), Diastolic (congestive) Heart Failure, Gastro-Esophageal Reflux disease (Acid reflex) without esophagitis(inflammation of the upper digestive tract), Asthma, Allergy, Dry eye syndrome of bilateral lacrimal glands (Tear glands), Posttraumatic Stress Disorder, Gout, Cough, Functional Dyspepsia(Indigestion), Acquired absence of right toe. Record review of Resident #1's [NAME] hospital Discharge summary dated 08/01//2023 revealed, a [AGE] year-old male who was admitted to a hosptal in [NAME] on 07/23/23 and his diagnoses did not include Post Traumatic Stress Disorder (PTSD). Record review of Resident #1's Care Plan, dated 08/03/23, revealed: I'm on psychotropic medications use related to (agitation PTSD): Chlorpromazine and the relevant interventions were Administer medications as ordered. Monitor/document for side effects and Effectiveness, consult with pharmacy, MD to consider dosage reduction when clinically appropriate, Discuss with MD, family re ongoing need for use of medication and Educate resident, family/caregivers about risks, benefits and the side effects of medication drugs being given. Record review of Resident #1's MDS, dated [DATE] revealed, Section C (BIMS) and Section N (Medications) were not completed. Record review of Resident #1's Physician Order dated 08/02/23 stated: Chlorpromazine HCl Oral Tablet 10 MG: Give 1 tablet by mouth one time a day for Agitation/PTSD. Order Date and D/C date were 08/02/2023 and 08/07/2023 respectively. Record review of Resident #1's MAR of August 2023 revealed that Chlorpromazine HCl Oral Tablet 10 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676272 If continuation sheet Page 5 of 11 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 08/10/2023 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 0658 MG was administered for PTSD/Agitation on 08/03/23,08/04/23, 08/05/23, 08/06/23 and 08/07/23. Level of Harm - Minimal harm or potential for actual harm In a telephone interview on 08/10/23 at 12:00 PM the FM stated she was an RN by profession and on 08/07/23 when she was going through Resident #1's MAR, she had noticed Resident#1 was administered with Chlorpromazine HCl Oral Tablet 10 MG once a day. The start date for this medication was 08/02/23 and was for Agitation/PTSD. FM stated Resident # 1 never diagnosed with PTSD or any other mental illness at any point of time in his life. She said she requested the NP to stop giving this unnecessary medication to him and NP discontinued the medication on 08/07/23 with immediate effect. FM said at the hospital, Resident #1 was prescribed for Chlorpromazine for hiccough (A characteristic sound like that of a cough due to the spasm of the diaphragm ) that he had developed after the surgery, and it was resolved before admitting to the facility. FM said no one from the facility explained to the resident or family about the rationale for administering this medication at the facility. She stated, had they discussed this with family and/or resident, this mistake could have been avoided. Residents Affected - Some In a telephone interview on 08/10/23 at 3:00PM Resident #1 stated he never had any kind of mental illness. Resident #1 said, on the admission day LVN A asked him if he had any mental illness since he had an antipsychotic medication in the list. Resident #1 reported, when he stated he was not diagnosed with any mental illness, LVN A stated he had to take a medication for some kind of mental illness since it was ordered by the NP (Resident was unable to name the medication as Chlorpromazine). When investigator asked him, if LVN A explained about the effect and side effect of the medication and what mental illness the medication was for, Resident #1 stated she did not. Resident #1 stated he would not have agreed to take that medication if he knew that it was for managing agitation since he was not an angry man. He stated, 3 days before the FM identified this mistake and made aware to the people at the facility In a telephone interview on 08/10/23 at 2:00 PM. the NP stated she discontinued Chlorpromazine on 08/07/23 on FM's request. When the investigator asked NP why Chlorpromazine was prescribed, NP stated since it was prescribed at the hospital and was listed in the discharge summary as home medication, she guessed Resident #1 might have some kind of mental illness. When investigator asked about the appropriateness of diagnosing mental illnesses based on guess work, NP said it was a mistake and never should have done that. She said she had requested medical record from VA since Resident #1 was a veteran, to confirm whether he had any mental illness. She added, since it takes time to get those records and the medication was already in the list of home medication, she thought Resident #1 had PTSD. When Investigator asked what would have been the appropriate action, she stated, before placing the order for Chlorpromazine she should have discuss with the hospital clinical staff, Resident #1 or FM for clarification. In a telephone interview on 08/10/23 at 2:00 PM, the MD stated administration of Chlorpromazine at a lower dose was not harmful to Resident #1 since he was taking it at the hospital and at the facility it was the continuation of it. When investigator asked, if diagnosing mental illness based on guess work was appropriate, he stated continuing the psychotropic medication irrespective of diagnosis was the right decision since stopping psychotropic medication suddenly have consequences to the safety of residents. He stated, generally the psychotropic medications were tapering down before discontinuation for avoiding the consequences from suddenly stopping the medication. When investigator pointed out that resident#1's Chlorpromazine stopped abruptly on 08/07/23 without tapering down, MD stated it was fine since the medication was already at a lower dose. In a telephone interview on 08/10/23 at 2:00 PM with the Pharmacist, she stated if resident had no justifiable diagnosis the prescribed Chlorpromazine was unnecessary. When the investigator asked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676272 If continuation sheet Page 6 of 11 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 08/10/2023 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some her, if she would have identified Chlorpromazine as an unwanted medication during her next MRR at the facility, RP stated it was most unlikely since the medication was in its lower dose with a diagnosis of PTSD. In an interview on 07/06/2023 at 2:21 PM, the DON stated, Since Chlorpromazine was ordered for a wrong diagnosis, the medication was unnecessary. She stated, the confusion occurred because the medication listed as home medication in the discharge summary from ASW hospital however the practice of diagnosing without any subjective or objective evidence did not meet professional standards. DON stated, since the medication was at its lower dose and taken at the facility only for 6 days, the possibility of any negative outcome was minimal. Before leaving the room after the interview DON took off the consent form created by LVN A. DON stated she was taking it away for shredding as it was not a valid document due to the lack of information like diagnosis, name of the medication, and other relevant information on it. DON stated the consent form created by NP was the valid one. Records review of facility policy Psychotropic drug use revised on 08/2017 reflected: It is the policy of this facility to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record . . 2.On admission, the admitting nurses will review the transfer orders for any psychotropic medications. All effort will be made by the Licensed Nurses to obtain as much history regarding these medications, including prior informed consents. from the previous facility or through resident or resident representative interview. Any information obtained will be documented in the resident's clinical record. 3.The Licensed Nurses shall review the classification of the drug, the appropriateness or the diagnosis, its indication/ behavior monitors and related adverse side effects prior to verification of admission orders with the Attending Physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676272 If continuation sheet Page 7 of 11 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 08/10/2023 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 - Some 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 interview and record review, the facility failed to ensure residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Resident #1) reviewed for unnecessary psychotropic medications. The facility failed to ensure Resident #1 was not prescribed Chlorpromazine HCL (an antipsychotic) based on the correct diagnostic criteria and assessment findings, for its use. This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication that was not indicated for use to treat medical conditions and symptoms. The findings included: Record review of Resident #1's face sheet, dated 08/10//2023, revealed a [AGE] year-old male whose admission to the facility was 08/02/2023. The resident had diagnoses of Cellulitis(Bacterial infection) of right toe, Osteomyelitis (inflammation or swelling of bone tissue ), right ankle and foot, Hypertension, Chronic Kidney Disease, Atherosclerotic heart disease( thickening or hardening of the arteries) of native coronary artery (Artery of the heart) without angina pectoris(Chest pain), Type 2 diabetes mellitus with diabetic nephropathy(the deterioration of kidney function.), Diastolic (congestive) Heart Failure, Gastro-Esophageal Reflux disease (Acid reflex) without esophagitis(inflammation of the upper digestive tract), Asthma, Allergy, Dry eye syndrome of bilateral lacrimal glands (Tear glands), Posttraumatic Stress Disorder, Gout, Cough, Functional Dyspepsia(Indigestion), Acquired absence of right toe. Record review of Resident #1's MDS assessment, dated 08/10/23 revealed, Section C (BIMS) and Section N (Medications) were not completed. Record review of Resident #1's Care Plan, dated 08/03/23, revealed: I'm on psychotropic medications use related to (agitation PTSD): Chlorpromazine and the relevant interventions were Administer medications as ordered. Monitor/document for side effects and Effectiveness, consult with pharmacy, MD to consider dosage reduction when clinically appropriate, Discuss with MD, family re ongoing need for use of medication and Educate resident, family/caregivers about risks, benefits and the side effects of medication drugs being given. Record review of Resident #1's Physician Order dated 08/02/23 stated: Chlorpromazine HCl Oral Tablet 10 MG (Chlorpromazine HCl): Give 1 tablet by mouth one time a day for Agitation/PTSD. Order Date and D/C date were 08/02/2023 and 08/07/2023 respectively. Record review of Resident #1's MAR of August 2023 revealed that Chlorpromazine HCl Oral Tablet 10 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676272 If continuation sheet Page 8 of 11 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 08/10/2023 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 MG was administered on 08/03/23,08/04/23, 08/05/23, 08/06/23 and 08/07/23 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's [NAME] hospital's Discharge summary dated 08/01//2023 revealed, a [AGE] year-old male who was admitted to a hospital in [NAME] on 07/23/23 and his diagnoses did not include Post Traumatic Stress Disorder (PTSD). Residents Affected - Some In a telephone interview on 08/10/23 at 12:00 PM, Resident #1's FM stated she was an RN by profession and on 08/07/23 when she was going through Resident #1's MAR, she had noticed Resident#1 was administered with Chlorpromazine HCl Oral Tablet 10 MG once a day. The start date for this medication was 08/02/23 and was for Agitation/PTSD. FM stated Resident # 1 was never diagnosed with PTSD or any other mental illness at any point of time in his life. She said she requested the NP to stop giving this unnecessary medication to him and NP discontinued the medication on 08/07/23 with immediate effect. FM said at the hospital, Resident #1 was prescribed for Chlorpromazine for hiccough (A characteristic sound like that of a cough due to the spasm of the diaphragm) that he had developed after the surgery, and it was resolved before admitting to the facility. FM said no one from the facility explained to the resident or family about the rationale for administering this medication at the facility. She stated, had they discussed this with family and/or resident, this mistake could have been avoided. In a telephone interview on 08/10/23 at 3:00 PM, Resident #1 stated he never had any kind of mental illness. Resident #1 said, on the admission day, LVN A asked him if he had any mental illness since he had an antipsychotic medication in the list. Resident #1 reported, when he stated he was not diagnosed with any mental illness, LVN A stated he had to take a medication for some kind of mental illness since it was ordered by the NP (Resident was unable to name the medication as Chlorpromazine). When investigator asked him, if LVN A explained about the effect and side effect of the medication and what mental illness the medication was for, Resident #1 stated she did not. Resident #1 stated he would not have agreed to take that medication if he knew that it was for managing agitation since he was not an angry man. He stated, 3 days before, the FM identified the mistake and made it aware to the people at the facility. During an interview and record review on 08/10/23 at 3:30 PM, LVN A stated that she was the nurse who went to get the consent for Chlorpromazine. LVN A stated, when she stated he had mental illness and there was a medication prescribed for that, Resident #1 reported to her that he never had a diagnosis of any mental illness. LVN A said, when she stated Chlorpromazine, an antipsychotic medication was there in the discharge medication list from the hospital, Resident #1 agreed to sign a consent form, stating there must be some reason then. LVN A showed a consent form that was dated 08/02/23 and signed by resident on the same day. Review of this form revealed, the consent form did not have the information about the diagnosis, diagnostic criteria, name of the medication, probable clinically significant side effect of the medication and need and benefit of the medication. When investigator asked LVN A, if she explained to Resident #1 about the basis of the diagnostic criteria, the medication and clinically significant side effects of the medication, LVN A stated she did not as it had to be done later by the NP who prescribed the medication. In a telephone interview on 08/10/23 at 2:00 PM, the NP stated she discontinued Chlorpromazine on 08/07/23 on FM's request. When the investigator asked NP why Chlorpromazine was prescribed, NP stated since it was prescribed at the hospital and was listed in the discharge summary as home medication, she guessed Resident #1 might have some kind of mental illness. When investigator asked about the appropriateness of diagnosing mental illnesses based on guess work, NP said it was a mistake and she never should have done that. She said she had requested medical records from VA since Resident #1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676272 If continuation sheet Page 9 of 11 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 08/10/2023 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 - Some was a veteran, to confirm whether he had any mental illness. She added, since it took time to get those records and the medication was already in the list of home medication, she thought Resident #1 had PTSD. When Investigator asked what would have been the appropriate action, she stated, before placing the order for Chlorpromazine she should have confirmed with the hospital clinical staff, Resident #1, or FM, why it was prescribed. When asked about the negative impact of the medication administered already for 6 days, NP stated since he was already taking it at the hospital and was on lower dose, there was very minimal possibility of any harm or side effects. In a telephone interview on 08/10/23 at 2:00 PM with the Pharmacist, she stated if Resident #1 had no justifiable diagnosis, the prescribed Chlorpromazine was unnecessary. When the investigator asked her, if she would have identified Chlorpromazine as an unwanted medication during her next MRR at the facility, RP stated it was most unlikely since the medication was in its lower dose with a valid diagnosis of PTSD. In a telephone interview on 08/10/23 at 2:30 PM, the MD stated administration of Chlorpromazine at a lower dose was not harmful to Resident #1 since he was taking it at the hospital and at the facility, was the continuation of it. When investigator asked, if diagnosing mental illness based on guess work was appropriate, he stated continuing the psychotropic medication, irrespective of diagnosis, was the right decision since stopping psychotropic medication suddenly could have consequences to the safety of residents. He stated, generally the psychotropic medications were tapered down, before discontinuation, for avoiding the consequences from suddenly stopping the medication. When investigator pointed out that Resident#1's Chlorpromazine stopped abruptly on 08/07/23 without tapering down, MD stated it was fine since the medication was already at a lower dose. He added, it was not reasonable to delay the order of psychotropic medications that residents were already receiving in the community, for a reason of obtaining informed consent. In an interview on 07/06/2023 at 4:00 PM, the DON stated, since Chlorpromazine was ordered for a wrong diagnosis, the medication was unnecessary, and the expectation was no unnecessary medication would be administered to any residents. She stated, the confusion occurred because the medication listed as home medication in the discharge summary from a hospital in [NAME]. However, diagnoses without accurate information was not the best practice. Since the medication was at its lower dose and taken at the facility only for 6 days, the possibility of any negative outcome was minimal. She added, if any issues aroused, the daily assessment for adverse effect of psychotropic medications would have identified those concerns. Moreover, the facility conducted psychotropic medication review in the routine meetings to identify unnecessary medications. Before leaving the room after the interview, DON took off the consent form created by LVN A. DON stated she was taking it away for shredding as it was not a valid document due to the lack of information like diagnosis, name of the medication, and other relevant information on it. DON stated the consent form created by NP was the valid one. Record review of the facility's policy titled Antipsychotic Medication Use revised in December 2016, revealed the following [in part]: Policy Interpretation and Implementation: 1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676272 If continuation sheet Page 10 of 11 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 08/10/2023 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 Record review of facility's policy Psychotropic drug use revised on 08/2017 reflected: Level of Harm - Minimal harm or potential for actual harm It is the policy of this facility to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record . Residents Affected - Some . Based on a comprehensive assessment of a resident, the facility will ensure that: 2.Residents do not receive psychotropic drugs pursuant to a PRN order unless medication is necessary to treat a diagnosed specific condition that is documented in the clinical record: . Psychotropic medications shall not be administered for the purpose of discipline or convenience. They are to be administered only when required to treat the resident's medical symptoms and will be considered only after nonpharmacological interventions have been attempted and failed. 2.On admission, the admitting nurses will review the transfer orders for any psychotropic medications. All effort will be made by the Licensed Nurses to obtain as much history regarding these medications, including prior informed consents from the previous facility or through resident or resident representative interview. Any information obtained will be documented in the resident's clinical record. 3.The Licensed Nurses shall review the classification of the drug, the appropriateness or the diagnosis, its indication/ behavior monitors and related adverse side effects prior to verification of admission orders with the Attending Physician. 4.The Attending Physician will review the resident's treatment plan, in collaboration with the consultant pharmacist. to calculate the use of the psychotropic medication and consider whether or not medication can be reduced or discontinued upon admission or soon after admission, during initial physician admission visit . Record review of the website https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3114667/#:~:text=Chlorpromazinex., accessed on 08/12/2023, revealed: Chlorpromazine is the only medication approved for hiccups by the US Food and Drug Administration, and for many years it was the drug of choice. Chlorpromazine is a dimethylamine derivative of phenothiazine. It acts centrally by dopamine antagonism in the hypothalamus. It has serious potential side effects, such as hypotension, urinary retention, glaucoma, and delirium, so it is generally no longer recommended as first-line management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676272 If continuation sheet Page 11 of 11