Health inspection·August 8, 2023

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was no bleeding, bruising, trauma or swelling present to any parts of Resident #1's body. Resident #1 denied any pain. When Resident #1 was asked about her personal safety she it was good, that the staff treated her with respect, and she had not seen staff treat others bad. Requested that psych service come out and evaluated Resident #1. Record review of a social services noted dated 8/7/23 at 11:30 a.m. indicated the following: SW consulted with Resident #1 regarding recent allegation. When asked about the recent allegation, Resident #1 stated I've been having hallucinations. Tell me what happened so I can apologize to people if I need to. Resident #1 reported she had been under more stress lately because her family was fighting amongst themselves. Resident #1 stated again, I can't think of anything that happened. I will ask the nurse; she will tell me. SW asked Resident #1 if she felt safe and Resident #1 responded yes. SW asked Resident #1 if anyone had threatened or hurt her in any way. Resident #1 responded no, they are afraid of me and I don't know why. SW encouraged Resident #1 to contact her if she had any concerns or needs. Record review of a social services noted dated 8/8/23 at 10:33 a.m. indicated the following: Referral for psych services faxed. Record review of a safe survey completed on 8/7/23 with Resident #1 indicated she denied knowledge of the allegation. Resident #1 stated she had been having hallucinations and asked for details of the allegations so she could apologize to any individuals that were involved but was unable to recall what happened or what was said. Record review of a witness statement dated 8/8/23 from LVN A indicated the following: On 8/4/23 Resident #1's hospice nurse aide came to the nurses station and told me that Resident #1 was making up stuff again. Hospice aide stated that Resident #1 said 3 maintenance men raped her but she didn't report it because she enjoyed it. Resident #1 came to the nurses station multiple times and I went to her room several times that day. Resident #1 never mentioned anything about it, and frequently made statements about things that did not happen. Resident #1 was not upset, her mood was good, and there was no evidence of any traumatic disturbance. Record review of witness statements from the maintenance supervisor, maintenance worker E and maintenance worker F, all indicated they were not present in the facility at the time allegation from Resident #1 were made. During entrance conference on 8/8/23 at 10:00 a.m., the Administrator said she had called in a self-report on 8/7/23. The Administrator stated it had to do with Resident #1 making and allegation of rape. The Administrator stated the incident occurred Friday, 8/4/23, but she did not find out about it until 8/7/23. The Administer stated Resident #1 told a Hospice aide that she had been raped by 3 maintenance men, on Thursday (8/6/23) evening, but did not report it because it felt good. The Administrator said the first time she was made aware of the incident was when the Hospice Social Worker called Monday 8/7/23 at around 10:31 a.m. and said she had left a voicemail on the facility's Social Worker's office phone Friday evening sometime between 4:15 and 5:00 p.m. The Hospice SW told the Administrator that she figured the SW was gone for the weekend, so she was calling to make sure they had received her message. The Administrator said she asked the Hospice SW if a Hospice nurse came out to assess Resident #1. The Hospice SW told her Hospice nurse C had come to the facility on Saturday 8/5/23 but did not know what time. The Administrator said she had no voicemail on her phone and had her SW check her messages. The SW checked her voicemails on Monday 8/7/23 and stated she had received (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675998 If continuation sheet Page 2 of 5 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 675998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Town Creek 2212 W Reagan St Palestine, TX 75801 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a voice message on Friday at around 4:20 p.m. but did not see it at the time. The Administrator said she sent the DON immediately to assess Resident #1 and had the SW start safe surveys while she started gathering facts for the self-report. During an interview on 8/8/23 at 11:30 a.m., the Administrator stated that while getting staff statements she discovered that LVN A had been notified about the incident involving Resident #1 on 8/4/23 by the Hospice aide and never reported it. During an interview on 8/8/23 at 11:45 a.m., Resident #1 was sitting in her wheelchair in the dining area. Resident #1 stated she had lived in the facility for 5-6 months, but really wasn't sure. Resident #1 stated the staff all treated her well, and that the food was excellent. Resident #1 stated no one in the facility had ever harmed her or touched her inappropriately. Resident #1 stated, I am a tattle tale and would report it immediately. I have never seen it happen, nor has it happened to me. Resident #1 stated the only 3 men that had come in her room were the man who brought her diapers, the AC man, and the medication man. Resident #1 did not know their names. Resident #1 stated they were never in her room at the same time. Resident #1 stated that she did have hallucinations, and the last time she had a hallucination was last Friday, and that must have been what they were talking about, but no one has ever harmed me. Resident #1 stated she knew when she was having hallucinations and would ask for medicine but did not recall the name of it. During an interview on 8/8/23 at 1:20 p.m., LVN B stated Resident #1 was alert, but forgetful at times. LVN B stated that on this date her and the maintenance man went into Resident #1's room to fix her tv. LVN B stated that after the incident last Friday, maintenance was not to go in Resident #1's room alone. LVN B stated she had not taken care of Resident #1 before this date but had not heard her say anything inappropriate. During an interview on 8/8/23 at 2:06 p.m., LVN A said she was working Friday 8/4/23 when the Hospice aide (did not know her name), came to the desk and said, Resident #1 is making up stuff again saying that 3 maintenance men raped her, and I know it is not true. LVN A said she went to Resident #1's room but did not mention anything about it. LVN A said the resident was not upset. LVN A said the Resident told the Hospice aide, she did not report the incident because it felt good. LVN A said, if I asked her if it happened, she would have spiraled. LVN A stated that spiraled meant she would go off on other things that did not happen. LVN A stated Resident #1 was known for saying things that were not always true. LVN A stated the DON and the Administrator had talked to her on this date, and she knew now that she should have reported the incident on Friday when it happened. During an interview on 8/8/23 at 2:17 p.m., Hospice RN Case Manager stated she first learned of the incident on Friday 8/4/23 during their team meeting at approximately 4:00 p.m. Hospice RN Case Manager statedManager stated the Hospice Social Worker had called the facility after the meeting. Hospice RN Case Manager stated she did not know at the time, but later found out the facility phones had rolled over to the after 5:00 p.m. phone number and voicemail. Hospice RN Case Manager stated she went to the facility on Monday 8/7/23 at 8:00 a.m. and did a complete assessment of Resident #1, with no visible signs of injury noted. Hospice RN Case Manager stated she had spoken to the Administrator and DON 8/7/23 at 9:00 a.m. and both told her they had received voicemails from the Hospice SW on 8/4/23 around 4:30 p.m. but did not actually know about them until the morning of Monday 8/7/23. Hospice RN Case Manager stated Resident #1 had no recollection of what she had told the Hospice aide on 8/4/23 and asked who she needed to apologize to. Hospice RN Case Manager stated Resident #1 had a history of saying things such as the aide had not come to bath her, when she actually had. Sated that Resident #1 had told her at some point that she had hallucinations and would sometimes see the walls (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675998 If continuation sheet Page 3 of 5 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 675998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Town Creek 2212 W Reagan St Palestine, TX 75801 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few moving. Hospice RN Case Manager said the Hospice Social Worker was currently out sick. Hospice RN Case Manager said Hospice nurse C was the nurse on call 8/5/23 and had not been able to contact her to verify that she went to the facility to assess Resident #1. During an interview on 8/8/23 at 2:30 p.m. the facility maintenance supervisor stated he had been made aware of the allegation from Resident #1. Stated he had 2 other men that worked with him, and none of them were in the building at the time the allegation was made. Stated his staff had been instructed not to go in Resident #1's room alone for any reason. During an interview on 8/8/23 at 2:50 p.m. the DON stated she had found out about the incident with Resident #1 on Monday morning 8/7/23. Stated she and the Administrator talked to LVN A, and she was told an allegation is an allegation and needed to be reported. DON stated disciplinary action was taken. During an interview on 8/8/23 at 3:06 p.m., CNA D stated Resident #1 had bouts of confusion. Stated she had heard the resident on 2 separate occasions talk sexually to a female Hospice nurse. CNA D stated she did not remember exactly what was said, or dates of occurrence. During an interview on 8/9/23 at 9:39 a.m., Hospice aide stated on Friday 8/4/23, at 2:50 p.m. she entered the facility. She went into Resident #1's room and was getting her ready to take a shower. Resident #1 stated, You know I've been raped by 3 guys last night?. Hospice aide stated she told Resident #1 not to say that, because it would get somebody in trouble. Hospice aide finished the shower and returned Resident #1 to her room. Hospice aide stated before she left the facility, she went to the nurses station. Stated there were 3 employees at the desk. Stated she did not know their names, and knew one was a nurse, and was not sure who the other 2 were, as there was always someone new. Hospice aide stated she told them, to protect your maintenance men, the resident said she was raped by 3 men. Hospice aide said staff did not think it was true, as the Resident makes a lot of stuff up. Hospice aide stated Resident #1 did have a history of saying things that were not true but could not give an example. Hospice aide stated one of the staff said, well, that's a new one, never heard that before, and they all laughed. Hospice aide said she called her Case Manager 8/4/23 at 3:39 p.m. and did not get an answer. Stated she called her boss at 3:40 p.m. and got no answer. She called the Hospice SW at 3:41 p.m. with no answer. Stated she tried the SW again at 3:57 p.m. and she answered. Hospice aide stated she told the SW what had happened. The Hospice aide stated that during the residents shower, she did not notice any signs on injury, and Resident #1 did not mention the incident again. Hospice aide stated that Resident #1 had recently moved from another room and had been a bit confused thinking some of her belongings were missing. Hospice aide stated she felt it was important to report this incident, even though she did not feel it happened. Record review of a facility Abuse Prohibition Guideline 2023 document indicated the following: .the Health Care Center will thoroughly investigate all alleged violations/allegations and take appropriate action. 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 . .if there is an allegation of rape, offer the resident/responsible parting sending the resident to the emergency room for rape/rape kit examination .Any employee who becomes aware of an allegation of abuse, neglect shall report the incident to a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675998 If continuation sheet Page 4 of 5 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 675998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Town Creek 2212 W Reagan St Palestine, TX 75801 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 0607 supervisor, DON or Administrator immediately. 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: 675998 If continuation sheet Page 5 of 5