Inspection·February 21, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Review of a Fall Risk Evaluation dated 02/04/2024 for Resident #1 reflected the total number of falls within the last 3 months were 1 or 2 times. Under Memory and Recall Ability it reflected in the last 7 days, Resident #1 never recalled three out of four of the following: current season, he/she is in a nursing home, location of room, staff names/faces. Under Gait, it revealed, Resident #1 gait was normal. Under Mobility, it revealed Resident #1 had no limitations. Residents Affected - Few Review of an un-witnessed fall incident report for Resident #1 dated 02/04/24 at 05:40 PM completed by LVN A reflected, This nurse entered Resident's room with meal tray and noted Resident laying on her right side in her roommate's bed. Attempted to assist Resident to upright position in bed, ineffective. Requested assistance from CNA staff. Upon standing, Resident immediately called out related to right hip and leg pain as well as right arm pain. Upon questioning Resident regarding pain Resident stated, I accidentally fell and hurt myself. Resident was unable to describe how fell happened. Her level of Pain was 9. Review of the progress notes for Resident #1 dated 02/04/2024 at 05:53 PM written by LVN A reflected, This nurse entered Resident's room with evening meal tray. Noted Resident laying on side in roommate's bed, shoes on floor beside bed. Attempted to help Resident sit up for mealtime. Resident unable to stand with assistance x1. Help requested from CNA staff with transfer. Upon attempted standing Resident, she called out right leg and hip pain. Resident also stated, my arm hurts too, regarding right arm. Upon questioning about what caused pain, Resident stated, I accidentally fell and hurt myself. Vitals were taken and within normal limits. Resident assisted to lying position in bed. Medical Director notified for emergency room transport due to pain and symptoms. EMS personnel arrived at the facility and Resident transported to NRH emergency room for evaluation and treatment. Review of the progress notes for Resident #1 dated 02/12/2024 at 06:36 PM written by LVN B reflected, Resident returned to facility via ambulance. Resident was diagnosed with right hip fracture and right wrist fracture. Resident had a wound vac to her right hip and a sling placed on her right wrist. Resident denies pain. Resident presented to facility with blisters and bruising to right thigh. Review of the hospital paperwork dated 02/04/2024 at 11:58 PM under Physical Summary for Resident #1 revealed, [AGE] year-old female, with advanced dementia, apparently had a fall at the nursing home on her right side. In the ER, she was noted to have both a femoral neck fracture as well as a wrist fracture on the right, currently splinted. Patient is unable to give any history secondary to dementia. The Imaging Results revealed, Pelvis CT shows proximal right femoral fracture and Wrist X-Ray shows right distal radius and ulnar fracture. During an attempted interview on 02/21/2024 at 12:45 PM with Resident #1, she was unable to explain how she sustained the multiple fractures. During an interview on 2/21/2024 at 3:20 PM with LVN A, she stated she went to assist with the trays and realized Resident #1 was not in the dining room. LVN A stated she took Resident #1's tray to her room and when she opened the door, Resident #1 was laying in her roommate's bed on her right side. LVN A stated she went to assist Resident #1 up because she was not getting up on her own. LVN A stated she realized Resident #1 was not sitting up as she normally does. LVN A stated she and CNA A attempted to sit Resident #1 up in bed and when they tried to stand her up, Resident #1 said her right leg and wrist hurt. LVN A stated there was swelling around Resident #1's wrist. LVN A stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675501 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 675501 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #1 was making vocal complaints of pain and they assisted her to lay back down. LVN A stated Resident #1 said she fell and hurt herself but could not tell her what happened or how she fell. LVN A stated she took Resident #1's vital signs and assessed her pain level. LVN A stated she notified everyone and called for transport to the Emergency Room. LVN A stated when the emergency personnel questioned Resident #1, she started talking about her grandmother which was not relevant to the questioning. LVN A stated the incident started around 5PM and she left work at 6PM and found out about the fracture when she returned to work the next morning. LVN A stated per policy, they must complete an Unwitnessed Fall Incident Report and complete notifications. LVN A stated they continue to treat any injuries or send the Resident out for further evaluation if necessary. LVN A stated by this incident not being reported to the State, there could possibly be things not being followed through or handled appropriately. LVN A stated she knows this is the purpose of reporting things to the State. LVN A stated she has never been in a situation where incidents were not reported to the State. During an interview on 02/16/2024 at 03:50 PM, CNA A stated she saw LVN A in Resident #1's room and asked if she needed help. CNA A stated LVN A said yes because she was having a hard time standing Resident #1 up. CNA A stated they both took an arm to assist Resident #1 up and Resident #1 yelled out it hurts. CNA A stated Resident #1 pointed to her right side. CNA A stated LVN A asked Resident #1 what happened, and Resident #1 said she fell. CNA A stated they repositioned Resident #1 into the bed she was already sitting. CNA A stated then LVN A sent Resident #1 out to the hospital for further evaluation. During an interview on 02/16/2024 at 04:20 PM, the DON stated she was informed by LVN A that Resident #1 told her she fell and when LVN A tried to help Resident #1 up, she could not stand, so she sent her out. The DON stated LVN A told her Resident #1 said, I did not tell anyone, but I fell and hurt myself earlier today. The DON stated she interviewed the CNAs, and no one saw or heard Resident #1 fall. The DON stated Resident #1 did not have any bruising or bleeding. The DON stated they follow the guidelines and depending on the severity and the scope, if the resident was not able to give an account, or it is an area of suspicion, it needs to be reported to the State. The DON stated everything is reported to the ADM, they complete an internal investigation, and all major injuries of a suspicious nature need to be reported to the State. During an interview on 02/16/2024 at 05:45 PM, the ADON stated in the group text she was informed Resident #1 informed LVN A she fell and due to her crying out in pain, LVN A sent Resident #1 out to the hospital for further evaluation. The ADON stated they later learned Resident #1 had sustained a fractured right hip and a fractured right wrist. The ADON stated the alleged fall was unwitnessed. The ADON stated when a Resident experiences an unwitnessed fall, you assess them and call EMS if necessary. The ADON stated a report should have been called into the Stated due to the fall being unwitnessed with major injuries and the resident not being able to say exactly what happened. During an interview on 02/16/2024 at 06:10 PM, the ADM stated at the time of the incident, Resident #1 was found laying on her right arm crooked in her roommate's bed. The ADM stated Resident #1 ambulates independently. The ADM stated LVN A reported she tried to get Resident #1 up for dinner and walk her over to her own bed. The ADM stated when LVN A and CNA A attempted to stand Resident #1 up, Resident #1 responded, Ow ow, I had an accident and fell. The ADM stated LVN A called the DON and herself to inform them Resident #1 was being sent out. The ADM stated the family member texted her on 02/4/2024 at 10:37 PM and informed her Resident #1's wrist and hip was broken. The ADM stated she did not report it as an unwitnessed fall with injury due to it not being suspicious. The ADM stated Resident #1 told LVN A she fell. The ADM stated there was no allegation of abuse or neglect. The ADM stated she conducted an internal investigation and discovered there was no foul play and the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675501 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 675501 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2024 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 0609 fell. The ADM stated she did not report the injury to the State because she did not deem it suspicious. Level of Harm - Minimal harm or potential for actual harm Review of facility policy titled, Abuse Prohibition Guideline 2023 reflected the following: Residents Affected - Few Injuries of Unknown Source: An injury should be classified as an injury of unknown source when both of the following conditions are met: 1. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and 2. The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. Investigations The Health Care Center will thoroughly investigate all alleged violations/allegations and take appropriate actions. No later than 2 hours if the allegation involves abuse or results in serious bodily injury, and no later than 24 hours if the allegation does not involve abuse and does not result in serious bodily injury. Reporting 4. The Health Care Center will report allegations to the state agency in accordance with state law. (Note timeframe requirement) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675501 If continuation sheet Page 4 of 4