Health inspection·January 29, 2026

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that he was not a vejito (little old man) who was crazy and that he could still make his own decisions. Resident #1 stated that he would have preferred to discuss what the medication was for. Resident #1 stated he was still in his right mind and only wanted the facility to reach out to FM B or FM if he was completely out of it and unable to make decisions. Resident #1 stated no one came in to ask him about getting the medication or if he wanted to take it. During an interview on 01/29/2026 at 1:07 PM, LVN A stated that she usually worked 6:00 AM to 6:00 PM shift. LVN A stated that there were a few residents with the flu and Tamiflu was given to other residents prophylactically as prescribed by the nurse practitioner. LVN A stated when there was a new medication order that the resident and their family were notified. LVN A stated that the nurse administered the first dose of the new medication. LVN A stated that it was important to notify the resident of medication changes because they were taking the medication and to be aware if they wanted to take the medication or not and to have an opportunity to ask questions or not. LVN A stated typically both the resident and family are notified depending on their BIMS score and if they can understand. LVN A stated Resident #1 was able to consent to his own treatment. LVN A stated Resident #1 was oriented to person, time, place and situation. LVN A stated that she does not recall if Resident #1 was notified of his new order for Tamiflu. LVN A stated she knew she told some residents, but could not recall who. LVN A stated someone helped with notification to families, but could not recall who. LVN A stated that resident rights included the right to take medication or not and the right to be notified of any changes in their treatment. During an interview on 01/29/2026 at 1:26 PM, RN B stated that the facility did prophylactic treatment to treat the flu. RN B stated that when there was a new order for medication she talked to the resident and also communicated with the provider and contact the family member listed on the resident's profile. RN B stated usually she would put in a progress note and specify that the family was contacted, ADON/DON, provider and that it was discussed with family. RN B stated that it was important to discuss changes in medication for the resident's autonomy, so they were aware of their care and to keep them involved of their care. RN B stated cognition level does not affect whether or not they are involved, and the resident should be notified regardless. During a telephone interview on 01/29/2026 at 2:02 PM, the ADON stated she was at training. The ADON stated that residents were started on Tamiflu prophylactically. The ADON stated she helped with notifying the families of the change. The ADON stated that the nurse or nurse practitioner was responsible to speak with the resident and tell the resident they were going to start Tamiflu. The ADON stated that sometimes Resident #1 was forgetful, but he recognized faces and sometimes had to be reminded of things that were done. The ADON stated it was important to notify residents of new medications so they were aware of what they were taking and what to expect. During an interview on 01/29/2026 at 2:08 PM, DON A stated that DON B was at a training and she was helping at the facility. DON A stated that the protocol for new medications would be for the nurse to notify the family member and if the resident was alert and oriented then the resident would be notified as well. DON A stated that it should be documented in a progress note and that included if the resident was notified as well. DON A stated notification to the resident depended on if they were aware of the medications they took, they can recall their daily routine, voice their needs and their BIMS score. DON A stated it was important to notify of any changes in medication so that the resident was aware of their plan of care. During an interview on 01/29/2026 at 2:42 PM, the ADM stated that he would defer notification of medications changes to the DON and it was not within his scope to answer. The ADM stated that documentation of notifications were also deferred to the DON. The ADM stated that it was important for the resident to be made aware of medications because it was apart of their place of care. The DON stated if the resident was alert and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676272 If continuation sheet Page 2 of 6 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 01/29/2026 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete oriented, they would be notified as well and their RP. During an exit conference interview on 01/29/2026 at 3:45 PM, DON B stated that Resident #1 was notified by the nurse practitioner that Tamiflu was being started. The DON stated that the nurse practitioner did not notify all residents, only some. The DON stated that Resident #1 had a BIMs of 12 and that his RP/FM was notified to start the medication. The DON stated that residents did not have to have a MPOA in place to notify the FM. Review of the facility policy titled ‘Resident Rights and Responsibilities, Notice of with revision date of 04/2025 reflected should a resident be found incompetent by a court of law, the resident's representative shall act on behalf of the resident. Event ID: Facility ID: 676272 If continuation sheet Page 3 of 6 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 01/29/2026 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 of 4 residents (Resident #1, Resident #2, and Resident #3) reviewed for homelike environment. The facility failed to ensure Resident #1's, Resident #2's and Resident #3's privacy curtains were free of stains. This failure could place residents at risk of living in an unclean or unsanitary environment, decreased quality of life, or shame. Findings included: Review of Resident #1's face sheet dated 01/29/2026 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of other cerebral infarction due to occlusion or stenosis of small artery (type of stroke caused by blockage or narrowing in deep-brain arteries), and hemiplegia and hemiparesis following cerebral infarction (motor impairments affecting one side of body following a stroke). Review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 12 which indicated moderate cognitive impairment. Observation on 01/29/2026 at 9:40 AM, revealed HSK on a ladder in Resident #1's room. Observation revealed privacy curtain in the middle of Resident #1's room was removed and replaced with a different curtain. During an interview on 01/29/2026 at 9:40 AM, Resident #1 stated that they were just now putting a new curtain up and that it had been dirty for at least three weeks. During a subsequent interview on 01/29/2026 at 11:05 AM, Resident #1 stated that his curtain was dirty for about 2 1/2 weeks. Resident #1 sated that CNA C changed his roommate and splattered bowel movement on the privacy curtain. Resident #1 stated CNA C tried to wipe it, but it stayed there. Resident #1 stated no one made an effort to clean it after that. Resident #1 stated that something similar happened once before. Resident #1 stated that FM B reported it to someone, but it was not changed until this morning (01/29/2026). Resident #1 stated that when his family visited they did not want to sit near the curtain. Resident #1 stated he does not want his room to be dirty. Review of Resident #2's face sheet revealed dated 01/29/2026 an [AGE] year-old female admitted on [DATE] with diagnoses of paroxysmal atrial fibrillation (type of irregular heart beat where heart rhythms start and stop on their own), muscle weakness and cognitive communication deficit (communication impairment caused by disruption in cognitive process like memory, attention and problem-solving). Review of Resident #2's annual MDS reflected a BIMS score of 14 no cognitive impairment. During an observation and interview on 01/29/2026 at 9:16 AM, it was revealed that Resident #2's privacy curtain between her and her roommate had several brown splattered dots. Resident #2 stated she did not know what was on her curtain and she wished it could be washed. Resident #2 stated that since she had been in her room she was not sure that the curtain was ever washed. Review of Resident #3's face sheet dated 01/29/2026 revealed a [AGE] year-old male admitted on [DATE] with diagnoses of post polio syndrome (neurological condition affecting polio survivors causing muscle weakness, fatigue, pain years after initial infection), major depressive disorder (mood disorder characterized by persistent sadness), and need for assistance with personal care. Review of Resident #3's quarterly MDS dated [DATE] reflected a BIMS of 15 which indicated no cognitive impairment. During an observation and interview on 01/29/2026 at 9:23 AM, it was revealed that Resident #3's privacy curtain in the middle of the room had brown streaks and spots. Resident #3 stated that he did not think the curtain got laundered very often, and he thought it was food. During an interview on 01/29/2026 at 12:44 PM, CNA D stated that when privacy curtains were soiled, they request to have the curtain taken down and laundered. This request was put into TELS (work order system). CNA D stated that TELS allowed for documentation as to why the curtain needed to be laundered and stated it was usually taken down the same day. CNA D stated she had no observed curtains with stains or that were soiled. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676272 If continuation sheet Page 4 of 6 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 01/29/2026 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 01/29/2026 at 12:58 PM, CNA C stated that she worked PRN at the facility. CNA C stated that she has put in a resident on TELS for the maintenance team and that she was informed with a curtain like that it needs to be quickly replaced. CNA C stated that she reported to maintenance this morning that Resident #1's curtain needed to be replaced and had not seen it that dirty before. CNA C stated that it had a black stain and was soiled. During an interview on 01/29/2026 at 1:07 PM, LVN A stated that if privacy curtains were stained or soiled that nursing staff could not take the curtain down and that it was put into TELS and they were to notify maintenance. LVN A stated if housekeeping was available they could also be notified as well, but it was usually put into TELS. LVN A stated there was one time Resident #1 brought to her attention the curtain was soiled in his room and she notified him she could not take the curtain down but could put it in TELs to get changed. LVN A stated she did not recall when this happened. LVN A stated the stain was a dark color and had smearing as if someone had attempted to wipe it, but she was unsure exactly what it was. LVN A stated she was not sure if there was a routine for laundering curtains. During an interview on 01/29/2026 at 1:26 PM, RN B stated she was unsure what the process was for laundering privacy curtains and unsure if there was a frequency at which they were laundered. During an interview on 01/29/2026 at 1:35 PM, the HSK stated that he was the laundry and house keeping supervisor and also helped with maintenance work orders if the MS was not there or if he had time to help. The HSK stated that this morning (01/29/2026) he removed the privacy curtain in Resident #1's room because it was a work order. The HSK stated that the urgency of getting the curtain laundered depended on the type of stain. The HSK stated if the note said there was bowel movement on the curtain it would be more urgent and it was to be changed right away. The HSK stated that privacy curtains were laundered on a deep cleaning schedule which occurred once a month for each room. The HSK stated that when the resident room was scheduled for deep cleaning the curtain was removed and laundered. The HSK stated that the curtain in Resident #1's room looked like it had something dried on it that was a dark black color, but he was unable to say what it was. During an interview on 01/29/2026 at 1:54 PM, the MS stated that soiled curtains were put into the TELS system as a work order. The MS stated that when a curtain was soiled, he tried to get it changed with in 24 hours. The MS stated that there was a rotation to have the curtains cleaned once a month when the resident rooms were deep cleaned and during that time the privacy curtains were taken down and laundered. The MS stated that if there was bodily fluids or bowel movement noted on the work order there was increased urgency to have it changed because bodily fluids would be an infection control issue. During a subsequent interview on 01/29/2026 at 2:00 PM, RN B stated that privacy curtains were laundered once a month and as needed and that the request could be put in through TELS. During an interview on 01/29/2026 at 2:42 PM, the ADM stated that privacy curtains were laundered as needed that that deep cleanings were done upon resident discharge. The ADM stated that staff were expected to report soiled privacy curtains through TELS. The ADM stated that MS and the ADM were responsible to monitor TELS and that a notification were received as soon as a request was put in. The ADM stated that he expected the soiled curtain to be changed as soon as possible. The ADM stated that if it was notated that bowel movement or bodily fluids were on the curtain the urgency was increased and the curtain should have been changed as soon as possible. The ADM stated that residents have the right to a clean environment. Review of work order logs reflected request for room [ROOM NUMBER] curtain to be changed due to large black stain, with request to be changed as soon as possible with an open date of 12/21/2025 and close date of 1/2/2026. Review reflected a second request for room [ROOM NUMBER] curtain to be changed with note It has had large stain on B side that looks like feces for well over 2 weeks. We have tried to report it multiple times with an open (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676272 If continuation sheet Page 5 of 6 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 01/29/2026 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete date of 12/31/2026 and close date of 01/2/2026. Review of work order log reflected request for Resident #1's curtain to be changed with note privacy curtain has BM on it with an open date of 01/08/2026 and close date of 01/15/2026. Review of work order log reflected request for Resident #1's curtain needed to be cleaned with an open date of 01/10/2026 and close date of 01/12/2026 with a note of repeat. Review of work order log reflected request for Resident #1's room with note privacy curtain needs to be washed with an open date of 1/14/2026 and close date of 1/15/2026. Review of work order log reflected request for Resident #1's curtain to be changed with note curtain has poop on it please change it with an open date of 01/27/2026 and close date of 01/29/2026. Review of facility policy titled Physical Environment with revision date of 05/2023 reflected the facility utilized TELS to track and document maintenance and regular tasks. Review reflected that it was the policy of the facility to establish procedures to ensure the facility remains in good working order for resident and staff safety. Event ID: Facility ID: 676272 If continuation sheet Page 6 of 6