Inspection·December 7, 2023

F 0602 pawn shop. RES #2's rings were returned on 11/27/2023. Level of Harm - Minimal harm or potential for actual harm Interview on observation on 12/7/2023 at 10:35 AM with RES #2 revealed he stated he was disappointed in himself and wished he had been able to respond differently and tell CNA A she could not take his rings. RES #2 thought he could trust CNA A because she was an employee; furthermore, he did not think someone who worked at the facility would commit such an act. RES # 2 felt like he lost some ability to trust people. RES #2 was observed wearing his rings at the time of the interview. Residents Affected - Few Record review of the Facility's PIR for Misappropriation of Property, dated 11/27/2023, indicated CNA A, an employee with a TA, exploited RES #2 on 11/20/2023 at 9:50 PM when she stole two gold rings. CNA A approached RES # 2 in the hallway, outside of his room, and told RES # 2 she would take 2 of his rings and have them cleaned. RES #2 handed over his jewelry, which he was wearing, and gave them to CNA A. CNA A left the facility with RES #2's property and did not return the jewelry. The PIR indicated CNA A did not respond to phone call attempts from the facility administration. Interview on 12/7/2023 at 9:05 AM with DET revealed she was the investigating officer to the report of misappropriation of property at the facility on 11/20/2023. DET stated the case was still open, but that the police department was able to track down CNA A to a local pawn shop. The DET stated CNA A was recorded on video having entered the pawn shop and sold RES #2's rings. The property was returned to RES #2 on 11/27/2023. A warrant for CNA A's arrest was initiated. Record review of CNA B written statement, undated, described she learned of the incident between CNA A and RES #2 right after it happened on 11/20/2023. CNA B walked to the parking lot and confronted CNA A about RES #2's rings and asked CNA A to come back inside to speak with the charge nurse. CNA A stated she would come back inside but did not return. It was reported that CNA A left the parking lot in her vehicle. Interview on 12/7/2023 at 2:10 PM with the [NAME] revealed the TA contracted with members of the medical field and provided them with a platform to pick up shifts from local agencies. The [NAME] stated each employee was considered a private contractor that each had to pass background checks and possess a current license in their field to be eligible for the platform. On the date of the interview, the [NAME] stated he had already removed CNA A from the TA platform, based on what he learned about CNA A having misappropriated property from RES #2 on 11/20/2023. Interview on 12/7/2023 at 2: 23 PM with the DON reflected the facility was responsible for the resident's welfare and it was the facility's responsibility to protect RES #1 and RES #2. The DON stated that the facility performed background checks before hiring an employee. Interview on 12/7/2023 at 12:45 PM with CNA B revealed she was an employee with the TA. CNA B stated the TA required drug tests, background checks, and a current license to pick up shifts on the platform. CNA B stated that TA employees do not always get to participate in regular employee trainings at the facility, but she knows to report misappropriation of property to the charge nurse and the ADM. Interview on 12/7/2023 at 3:05 PM with RN A revealed all staff must go through a background check before hired and must pass yearly employee misconduct checks. RN A stated that criminal background checks only worked if an employee had a documented criminal history, and the facility could not tell what an employee might do. RN A stated that the facility trained its employees to recognize suspicious employee behavior and report misappropriation of a resident's property to the charge nurse and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675501 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 675501 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Corsicana Rehabilitation and Healthcare 3300 W 2nd Ave Corsicana, TX 75110 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 0602 ADM immediately. Level of Harm - Minimal harm or potential for actual harm Interview on 12/7/2023 at 3:10 PM with HK A revealed the facility trained housekeeping staff to respect resident's property and it was never ok to take something from a resident. HK A stated any incidents of misappropriation of property were reported to her supervisor immediately. Residents Affected - Few Interview on 12/7/2023 at 3:30 PM with LVN B revealed she was trained on Misappropriation of Property as a part of facility training. Most recently, an in-service was given for Resident Rights. LVN B stated she would report suspicious behavior of an employee and misappropriation of property to the ADM. Interview on 12/7/2023 at 4:30 PM with the facility SW revealed she spoke with RES #1 and RES #2 on 11/21/2023, the morning after the incident on 11/20/2023. The SW stated that RES #1 and RES #2 were pleased with how the facility was overseeing the incident with CNA A and RES #2. The SW described RES #1 and RES #2's mood as a little sad and stated RES #1 and RES #2 were a resilient couple and did not let things get them down. Interview on 12/7/23 at 5:00 PM with the ADM revealed CNA A's first day as a TA employee at the facility was on 11/20/2023, which was the same day of the incident of Misappropriation of Property. CNA A's last date of eligibility for employment was on 11/20/2023 and CNA A has not been allowed to return to the facility. The ADM felt she did everything she could do to get RES #2's jewelry back. She stated she spoke to the police, provided pictures of the rings to the police, and kept RES #1 and RES #2 informed every step of the way. The ADM called the TA, with which CNA A contracted, and told the [NAME] what occurred. She stated the [NAME] decided to remove CNA A from the platform. The ADM stated she spent at least 30 minutes a day with RES # 1 and RES #2 since the incident on 11/20/2023 and did not notice any decline, changes in behaviors, or deviation from normal routine. The ADM stated the facility policy for valuable items was covered in Abuse Prohibition Guideline and RES #2 was counseled on wearing expensive jewelry and encouraged to keep expensive jewelry locked up or sent home with family. Record review of RES #2's PN from a clinical counseling service performed by PSY D, dated 11/27/2023, reflected a counseling session, where RES #1 and RES #2 shared grief regarding an incident, which resulted in the loss of the resident's jewelry. Support was provided and both residents stated they felt confident and appreciated how the administration oversaw the situation. Both residents reported they enjoyed living at the facility and felt safe. Record review of the facility Abuse Prohibition Guideline in-services, dated 2023, reflected Misappropriation of Property includes but is not limited to the deliberate misplacement, exploitation, or wrongful temporary or permanent use of your residents' belongings or money without the resident's consent. The Abuse Prohibition Guideline identified procedures for prevention of misappropriation of resident's property by (1) upon admission, the health care center will assist the resident and resident family to identify and mark personal possessions; and (8) the healthcare center will educate the family and residents on risks associated with keeping valuable items and options for safe keeping, such as taking them home or storing them in a lockbox. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675501 If continuation sheet Page 3 of 3