Health inspection·September 10, 2025

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Resident #4's admission Record dated 9/10/2025 was documented he was admitted on 7/12024 with diagnoses of Muscular Dystrophy (a group of genetic disorders that cause progressive muscle weakness and loss. contracture to multiple sites, muscle weakness (difficulty swallowing, involves trouble moving food or liquid from the mouth to the stomach), cognitive communications deficit, and need for assistance with personal care. Record review of Resident #4's consolidated orders for September 2025 was documented he had a regular diet. Record review of Resident #4's Quarterly MDS dated [DATE] was documented BIMS score 15/15 (cognitively intact), and ADL for eating was independent. Record review of Resident #4's Care Plan dated 8/18/2025 was documented for eating he required a tray set up assistance and supervision for meals. Observation on 9/9/2025 at 12:18 PM in the Dining room revealed Resident # 4 was sitting down and [NAME] his lunch and had the alternate hamburger, the bread was not burned. Interview on 9/9/2025 at 12:19 PM in the Dining room Resident #4 stated the residents often have burned food and does not eat it or ask for an alternative. Interview on 9/10/2025 at 2:39 PM DON had no response when discussed the bread was burned at bottom for lunch. Interview on 9/10/2025 at 2:44 PM FSM stated she did help the cook with the lunch meal but did not see any burned bread or get complaints. Policy requested from Administrator on 09/10/2025, Administrator provided surveyor with Texas Food Establishment Rules, dated August 2021 Event ID: Facility ID: 676392 If continuation sheet Page 2 of 4 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 09/10/2025 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement COVID-19 immunizations policies and procedures to ensure that resident's medical record includes documentation that indicates that the resident or resident representative was offered provided education regarding the benefits and potential risks associated with COVID-19 vaccine for 1 of 5 (#1) residents reviewed for COVID-19 vaccination status in that:The facility failed to provide documentation that Residents #1 had received education regarding the benefits and potential risks associated with COVID-19 vaccine.These failures placed residents at risk for not being informed/educated about immunization and decline in health status. infections, the transmission of infectious disease, and a decline in health status. Findings included: Record review of Resident #1's admission Record was documented she was admitted on [DATE], re-admit date [DATE] with diagnoses of heart failure, acute respiratory failure, dementia, cognitive communication deficit, and need for personal assistance.Record review of Resident #1's consolidated orders for September 2025 documented she had a personal history of COVID-19.Record review of Resident #1's Quarterly MDS dated [DATE] documented BIMS score was 12/15 (moderately cognitive impairment), ADL was documented was independent for eating.Record review of Resident #1's Care Plan dated 8/6/2025 documented no care plan for the COVID-19 vaccination.Record review of Resident #1's consent form dated 10/4/2024 documented, her responsible party signed a consent for the COVID-19 Vaccine. Record review of Resident #1's neurologist visit dated 8/27/2025 documented in 2021, she was in the hospital with COVID-19.Record review of Resident #1's chart documented she received her last COVID-19 vaccination on 12/22/2023. Interview on 9/10/2025 at 11:34 AM the RP for Resident #1 stated she had consented for Resident #1 to have a CVOID-19 vaccination, and the facility had not provided this to her. Interview on 9/10/2025 at 5:45 PM the DON stated the resident should have been offered a COVID-19 vaccine yearly with a consent form. Interview on 9/10/2025 at 6:02 PM with RN A, who was the previous ADON, stated she was not sure they were still administering COVID-19 vaccines for residents. No Covid-19 vaccine was provided to Resident #1. Interview on 9/10/2025 at 7 :30 PM with ADM stated, if the family/residents provided consent the facility will provide a COVID vaccination to the resident.Record review of policy, COVID-19, no date was documented It is the policy of this facility to ensure that: When COVID-19 vaccine is available to the facility, each resident and staff member is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident or staff member has already been immunized per the CDC recommendations. Before offering COVID-19 vaccine, each resident or the resident representative receives education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine. The resident, resident representative, or staff member has the opportunity to accept or refuse a COVID-19 vaccine and change their decision. The resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine; and PURPOSE: To minimize the risk of residents acquiring, transmitting, or experiencing complications from COVID-19 by ensuring that each resident: Is informed about the benefits and risks of immunization. Has the opportunity to receive, unless medically contraindicated or refused or already immunized, the COVID-19 vaccine. Offering vaccinations: The facility will offer residents and staff vaccination against COVID-19 when vaccine supplies are available to the facility through the facility's pharmacy partner. If the resident' resident representative consented to the vaccine, a physician's order will be obtained for the COVID-19 vaccine. For residents who receive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676392 If continuation sheet Page 3 of 4 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 09/10/2025 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 0887 vaccination, the following information will be documented in the resident's electronic health record: The date of vaccination Lot number, Expiration date, Site of vaccination, Name of person administering the vaccine. 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: 676392 If continuation sheet Page 4 of 4