Health inspection·January 22, 2024

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pleuritic pain, accessory muscle usage, skin color. - Oxygen settings: oxygen at 2 Liters Per Minute (LPM) via nasal cannula. Record review of Resident #1's MDS assessment dated [DATE] indicated Resident #1 has ability to understand others and had the ability to express ideas and wants. She had Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately cognitively intact. Also, Section O under special treatments and programs was checked for oxygen therapy. Record review of intake investigation worksheet for complaint intake ID 476528 received on 1/12/24 revealed Resident #1 must be on continuous oxygen for shortness of breath. The facility staff did not check her tank regularly and on over 20 occasions the complainant had notified the tank was on red (out of oxygen). This would happen particularly on Sundays when the tank was on red. Resident #1 could be seen gasping for air and when she was in her room, she was supposed to be switched to the wall unit but that was not being done by some of the staff. Resident #1 was kept on the tank on her wheelchair, which tends to run out of oxygen quickly. The issue had been reported to the facility for the past two weeks with no resolution. During an observation and interview on 1/22/24 at 1:42 p.m., Resident #1 was in room up in wheelchair, wearing oxygen nasal cannula. The portable oxygen tank strapped to the back of her wheelchair gauge was in the red section and needle pointed past passed the number zero indicating the tank was empty. At time of the observation Resident #1 stated she felt good and was not short of breath. During an observation and interview via phone on 1/22/24 at 2:35 p.m., Resident #1's family member said another family member visited Resident #1 earlier that day before lunch and notified someone (unknown name) at the nurse station that Resident #1's tank was empty. The family member said Resident #1's portable oxygen tank recently had been emptied several times and facility had been made aware but was still an ongoing issue and concern. Resident #1 was on room concentrator at that time. During an interview on 1/22/24 at 2:55 p.m., LVN D she was not the staff who Resident #1 family member spoken to earlier and she was not aware Resident #1's family member voiced her portable oxygen tank was empty. She said she was the staff who transferred Resident #1 from the empty portable tank to the room concentrator. LVN D said she was on Unit- RR doing rounds when the DON was in Resident #1's room and notified her Resident #1's portable tank was empty. She said she was not aware how long Resident #1 had gone without oxygen. LVN D said on Unit- RR she had three total residents on oxygen , but Resident #1 was mainly her only resident who was up in wheelchair and used the portable oxygen tanks frequently. She said Resident #1 often ran out of air and Resident #1 was good about coming to her and letting her know and she would swap out her tank for another tank. LVN D pointed behind the nurse station at the portable tank refill machine and explained it would take up to 5 hours to refill an entire standard size portable oxygen tank. She said she had never been able to refill an entire tank during her shift and she often rotated between the tanks refilling so she could have more than one tank to choose from among the residents. LVN D said the portable tanks were not full when they are given to the residents and that was why Resident #1 tank was frequently going empty and needing to be changed out. LVN D said Resident #1's family had notified her in the past regarding Resident #1 tank was empty and whenever they tell her she would change it out. During an interview on 1/22/24 at 3:47 p.m., the DON said Resident #1 had voiced to her in the past about Resident #1's oxygen tank being empty. She said staff should check randomly if a resident was up and using portable tanks. The DON said she had visited with Resident #1 earlier and noticed the tank was low, so she asked LVN D to change it. (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 01/22/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and interview on 1/22/24 at 5:13 p.m., of the Medication room on Unit -RR was an empty oxygen tank stored in the corner on the floor, unsecured. The DON said the empty oxygen tank should not be stored on the floor and should be in a tank holder or properly stored in the oxygen storage closet on Unit-JC . The DON removed the oxygen tank and gave it to another staff to take away. 2. During an observation and interview on 1/13/24 at 12:09 p.m., and on 1/22/24 at 2:27 p.m., Resident #2 oxygen concentrator was stored next to the bedside table which had three 3oz bottles of Biofreeze Menthol 4% - manufacture label: Flammable; two 7.1 oz bottles of Theraworx Relief contains magnesium sulfate (muscle cramp and spasm relief); open undated box of 70 single use vials of lubricant eye drops, contains carboxymethylcellulose sodium 0.5% (moisturizes and relieves dry, irritated eyes); and an open 1.75 oz jar of Vaseline, contained 100% pure petroleum jelly; and One economy size bottle of lotion. Resident #2 said a family member had purchased most of the items on the bedside table and staff had not told her she was not allowed to have those items in her room. She said a family member or sometimes staff if she asked would help give and/or rub on the medications for her. During an observation and interview on 1/22/24 at 5:31p.m., the DON said said no medications should be left at bedside unless the resident was assessed to self-administer; she said the facility did not have any residents who self-administered therefore, no medications should be at bedside to self-administer. State Surveyor notified the DON regarding Resident #2's medications at bedside and the DON notified Resident #2 that she was not allowed to keep medications at bedside and she removed the following items: Three bottles of Bio Freeze, Two bottles of Theraworx, open box of vials of eye drops, one bottle of vitamins, and one saline bottle (DON said she did not know why saline bottle was in Resident #2's room because they mainly used saline for wounds and Resident #2 did not have any wounds). The DON said she was not aware at that time if Resident #2 had orders for any of the items she removed from Resident #2's room. During an interview on 1/22/24 at 7:42 p.m., the Administrator said they did not have an oxygen storage policy, but she contacted her regional nurse who notified her oxygen tanks are to be stored on a stand or secured. Record review of revised oxygen administration policy dated October 2010 revealed purpose of this procedure was to provide guidelines for safe oxygen administration . Equipment and Supplies: 1) Portable oxygen cylinder (strapped to the stand) .Steps in the Procedure: .4) Remove all potentially flammable items (e.g., lotions, oils, alcohol, smoking articles, etc.) from the immediate area where the oxygen is to be administered. 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 01/22/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility failed to ensure medications were secured on 1 of 3 medication carts reviewed for pharmacy services. (Unit-RR Medication Aide Cart) -Medication Aide Cart for Unit-RR was left unlocked, unsecured, and unattended near the nurse station. -Seven medications were stored a bedside of Resident #2 . These failures could affect the residents, who resided on Unit-RR and received medications from these carts, by placing them at risk of drug diversions or misuse of medications. Findings included: During an observation on 1/13/24 at 11:03 a.m., revealed the Medication Aide Cart for Unit-RR had an unopened 30 count blister pack of Amlodipine Besylate 10 mg tablets (it works by relaxing your blood vessels to lower your blood pressure) unsecured and unattended on top of the cart. The cart was unlocked, and unattended stored against the wall in the dining room on Unit-RR for unknown amount of time. Residents and staff were observed passing by the medication cart. During an observation and interview on 1/13/24 at 12:09 p.m., and on 1/22/24 at 2:27 p.m., Resident #2 at bedside had an open undated bottle of 240 count women's multi dietary supplement (for energy, immunity, and healthy appearance); three 3oz bottles of Biofreeze Menthol 4% (relieves minor aches and pains of muscles and joint); two 7.1 oz bottles of Theraworx Relief contains magnesium sulfate (muscle cramp and spasm relief); open undated box of 70 single use vials of lubricant eye drops, contains carboxymethylcellulose sodium 0.5% (moisturizes and relieves dry, irritated eyes); and an open 1.75 oz jar of Vaseline, contained 100% pure petroleum jelly. Resident #2 said a family member had purchased most of the items on the bedside table and staff had not told her she was not allowed to have those items in her room. She said a family member or sometimes staff if she asked would help give and/or rub on the medications for her. During an observation on 1/20/24 at 8:37 p.m., revealed the Medication Aide Cart for Unit-RR was unlocked, and unattended stored against the wall in the dining room on Unit-RR for unknown amount of time. All the drawers of the medication could be opened, and the medication was easily accessible. A resident was observed wondering in the dining room on Unit-RR by the medication cart. During an interview on 1/20/24 at 8:45 p.m., Agency LVN B she was responsible for leaving the medication aide cart unlocked, she said staff from another hall was needing something from the cart and she unlocked the cart and forgot to lock the cart. Agency LVN B said the medication carts are never supposed to be left unlocked and don't know why she did it, was a mistake. During an interview on 1/22/24 at 2:55 p.m., LVN D said she was the charge nurse for Unit- RR and said there was no residents on her Unit who self-administered medications and was not aware of residents on her Unit who had medications at bedside. LVN D said if she was aware of medications in residents' room, she would remove it and notify DON. (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 01/22/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 1/22/24 at CMA C said she was not aware of any residents who self-administered medications. Also, said residents were not allowed to keep medications in their room and she was not aware of any residents who had medications stored in their room. CMA C said if she was to see medications in a resident room she would remove it and notify the nurse. During an observation and interview on 1/22/24 at 5:31p.m., the DON said medication carts should remain locked and secured anytime not attended. She said no medications should be left at bedside unless the resident was assessed to self-administer; she said the facility did not have any residents who self-administered therefore, no medications should be at bedside to self-administer. State Surveyor notified the DON regarding Resident #2's medications at bedside and the DON notified Resident #2 that she was not allowed to keep medications at bedside and she removed the following items: Three bottles of Bio Freeze, Two bottles of Theraworx, open box of vials of eye drops, one bottle of vitamins, and one saline bottle (DON said she did not know why saline bottle was in Resident #2's room because they mainly used saline for wounds and Resident #2 did not have any wounds). The DON said she was not aware at that time if Resident #2 had orders for any of the items she removed from Resident #2's room. During an interview on 1/22/24 at 5:30 p.m., LVN D said she was aware Resident #2 had medications at bedside and said she did not give Resident #2 the medications and she instructed her CNAs to not give Resident #2 the bedside medications. LVN D said she did not notify DON or the Administrator regarding Resident #2's medications she had stored at bedside and said she probably should have. Record review of storage of medication revised policy dated April 2007 revealed The facility shall store all drugs and biologicals in a safe, secure, and orderly manner . 7) Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675998 If continuation sheet Page 5 of 5