Health inspection·November 21, 2023

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 interview and record review the facility failed to report alleged violations related to abuse and report the results of all investigations to the proper authorities within prescribed timeframes for one (Resident #1) of five residents reviewed for abuse and neglect, in that: The facility failed to report an allegation of neglect to the State Agency when Resident #1 was found in her room with a steak knife and voicing suicidal intent. This failure placed residents at risk of further abuse or neglect. Findings Included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including major depressive disorder, general anxiety disorder, unspecified dementia, and frontal lobe and executive function deficit following other cerebrovascular disease (includes a variety of medical conditions that affect the blood vessels of the brain and the cerebral circulation). Review of Resident #1's quarterly MDS assessment, dated 09/21/23, reflected a BIMS of 12, indicating a moderate cognitive impairment. Section D (Mood) reflected she had little interest or pleasure in doing things, felt down, depressed, or hopeless, and felt bad about herself nearly every day. Review of Resident #1's quarterly care plan, revised 10/07/23, reflected she was at risk for potential for a psychosocial well-being problem with an intervention of evaluating her emotional status. She had potential for mood problem with an intervention of monitoring/recording/reporting to MD mood patterns or s/sx of depression, anxiety, or sad mood. Review of Resident #1's progress notes in her EMR, dated 09/05/23 and documented by LVN A, reflected the following: Around 4:15 PM, [LVN A] went into [Resident #1]'s room to admin topical analgesic medications and topical lotions to BLE. [Resident #1] was not tearful nor in any distress. At 5:58 PM, [LVN A] received a call from [Resident #1]'s [FM B], asking [LVN A] to check on [Resident #1]. [FM B] stated [Resident #1] called him tearful, stated she loved [FM B] and hung up. [FM B] said he tried calling her back, but she did not answer. [FM B] yelled at [LVN A] to check on her, then hung up. Immediately after that phone call, [LVN A] asked CNA to check on [Resident #1]. At 6:05 PM, CNA called [LVN A] and said I (LVN A) was needed ASAP. [LVN A] immediately went to [Resident #1]'s room. [LVN A] noted CNA (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 3 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 (X3) DATE SURVEY COMPLETED A. Building 11/21/2023 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)