Health inspection·February 29, 2024

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #2's skin assessment on 2/8/24 read: Skin is warm, dry, and intact. Skin color and turgor WNL. No new issues noted at this time. No .pain/discomfort at time of assessment. Record review of Resident #2's clinical record revealed a CP meeting held on 2/9/24 and 2/20/24 which addressed ADL care.[At the 2/9/24 meeting Family Member A and DON attended. While at the 2/20/24 meeting Family Member A and the Administrator attended the meeting.] Observation and interview on 2/27/24 at 1:58 PM revealed , Resident #2 was in bed, assisted by Family Member A in eating the lunch meal. The resident was alert but not oriented. There were no injuries, skin tears or bruises present on Resident #2. There was no odor of urine or feces. The resident did not have the cognitive ability to trigger the call light. Family Member A stated, the ADL care around toileting had improved after the 2/9/24 CP meeting, after the family member complained to the DON. Family Member A stated that the lack of timely incontinent care for Resident #2 could have resulted in UTIs. Family Member A stated, I visit every day .there was no brief change for 2 days for 8 hours [2/7/24-2/8/24] .we spoke to the DON .I was with her [Resident #2] all day in the COVID Unit and pushed the call light and no one came to provide toileting [for Resident #2] we had a care management meeting 2/9/24 and another one on 2/20/24 to regroup after her antibiotics regimen ended and discussed incontinent care response . Family Member A further stated: she complained to the DON; the resident was lethargic on both days (2/7/24-2/8/24); the lack of staff response was on [ 2/7/24] from the day shift and on [2/8/24] the day and evening shift. [shifts were 6 AM-2 PM, 2 PM-10 PM, and 10 PM to 6 AM]. During a telephone interview on 02/28/24 at 10:52 AM, Family Member B stated that on 2/7/24 and 2/8/24 Resident #2 went without incontinent care for 8 hours each day. Family Member B recalled that the lack of incontinent care was during the day and the evening shift. Family Member B stated that Family Member A had to change Resident #2's brief on 2/7/24 and 2/8/24. Family Member B stated that Family Member A complained to nursing and was told there was a shortage of staff. Also, Family Member B stated he was told by nursing staff that brief changes were scheduled for every four hours. Family Member B stated that after 2/9/24, incontinent care for Resident #2 improved and there was no skin issues related to incontinent care. During an interview on 2/28/24 at 11:03 AM, CNA C [did not remember the shift worked] stated she provided ADL care to Resident #2 in February 2024 that included incontinent care, assistance with eating, and bathing and grooming. I remembered changing the brief of [Resident #2] on 2/7/24 and 2/8/24 and documented in the ADL sheet .I did not neglect the resident for 8 hours each day. CNA C stated nursing practice was to check on the resident every two hours and check as to whether the resident needed a brief change. CNA C stated that incontinent care could be given as needed based on the resident or family requesting a brief change. During an interview on 2/28/24 at 11:22 AM, LVN D, stated part of nursing care was to check on ADLs for Resident #2. The policy was to check on incontinent care every 2 hours. LVN D stated that he did not remember that Resident #2 did not receive incontinent care for periods of 8 hours on 2/7/24 and 2/8/24. LVN D stated his shift was from 6AM-2PM. LVN D stated that the family did not complain to him about incontinent care. LVN D did not recall whether Resident #2's call light was triggered on 2/7/24 and 2/8/24. LVN D stated he received training on abuse and neglect. During an interview on 2/28/24 at 11:44 AM, the DON stated staffing was adequate to meet ADL needs on 2/7/24 and 2/8/24. The DON stated that the staff documented incorrectly that incontinent care did not occur. The DON stated the latter documentation was incorrect because the ADL sheet for Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676392 If continuation sheet Page 2 of 3 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 676392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #2 on 2/7/24 and 2/8/24 revealed that incontinent care was provided at least once every shift. The DON stated that she was not sure why there was an allegation of call light response on 2/7/24 and 2/8/24 and staff not responding to provide incontinent care to Resident #2. The DON stated she could not recall whether Family Member A or Family Member B reached out to her to complain about incontinent care for Resident #2 on 2/7/24 and 2/8/24. The DON stated she physically was present to check on call light response on 2/9/24 in response that a family member [Family Member A] made a comment to the Administrator about lack of call light response and incontinent care. The DON stated that Resident #2 did not have the cognitive ability to trigger the call .therefore needed to check on her every two hours. During an interview on 2/28/24 at 12:04 PM, the Administrator stated on 2/9/24 a family member made a comment that there was a slow response to call light on 2/7/24 and 2/8/24. The Administrator informed the DON to check the call light issue. The Administrator stated that on 2/9/24 there was a regularly scheduled CP meeting and on 2/20/24 there was another CP meeting. At the 2/20/24 CP meeting the Administrator stated a family member expressed a concern over the call response in the past (2/7-2/8/24) involving Resident #2. The Administrator stated that incontinent care and call light response was not an issue moving forward. The Administrator stated in response to a Resident Council grievance dated 2/21/24 about late call light response, nursing staff was in-service on call light response and an audit was done by the DON and completed on 2/25/24; no negative findings involving call light response and incontinent care. Record review of the facility's Incontinent Care policy dated Revised 05/2007 read: .remove urine or feces from skin .[The policy did not address when incontinent should be done.] Record review of facility's Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment dated revised 10/2022 read: Neglect is the failure of the facility .to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676392 If continuation sheet Page 3 of 3