Health inspection·April 14, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life by failing to assure dignity and respect were provided for 2 of 2 residents (Resident #11 and Resident #67) reviewed for privacy and dignity issues. Resident #11 and Resident #67's abdomens were exposed in the multi-purpose room of the locked unit during their subcutaneous injection of insulin, that was administered by LVN D. This failure could cause residents to feel uncomfortable and disrespected. Findings include: Record Review of Resident #67's clinical records reveal an [AGE] year-old female resident admitted to facility 03/07/2021 with diagnosis, but not limited to include: UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL 01/20/2021 Primary DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS 01/20/2021 Other MILD COGNITIVE IMPAIRMENT OF UNCERTAIN OR UNKNOWN ETIOLOGY LONG TERM (CURRENT) USE OF INSULIN Record review of Resident #67's physician order revealed the following: Novolog Pen (Insulin Aspart Flexpen) per sliding scale for hyperglycemia (elevated blood glucose), and MDS shows a BIMS score of 5. 04/12/23 11:08 AM-During observation, Resident #67 received insulin in the multi-purpose room of the locked unit in front of family member and multiple other residents. Insulin was given in the LLQ of abdomen. LVN D lifted shirt for this medication to be administered. 04/13/2023-During an interview, Resident #67 was unable to answer any questions regarding how it made her feel to have medication administered in the multi-purpose room of the locked unit. Page 1 of 19 676010 676010 04/14/2023 Legacy Rehabilitation and Living 4033 W 51st Ave Amarillo, TX 79109

F 0550 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #11's clinical records reveal a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses, but not limited to include: UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL 01/20/2021 Primary DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY Residents Affected - Few ALTERED MENTAL STATUS, UNSPECIFIED 04/12/2022 4 TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS 01/20/2021 Other MILD COGNITIVE IMPAIRMENT OF UNCERTAIN OR UNKNOWN ETIOLOGY 01/20/2021 Other LONG TERM (CURRENT) USE OF INSULIN Record review of Resident #11's physician order dated 1-13-2020 revealed the following: HumaLOG Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 200 - 250 = 2 units; 251 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 - 450 = 10 units; 451+ notify provider, subcutaneously before meals for Diabetes /hyperglycemia MDS shows a BIMS score of 3 for resident #11. During observation: 04/12/23 11:19 AM -observed resident #11 receiving insulin in the LLQ in the multi-purpose room of the locked unit in front of multiple other residents in the room. Resident's shirt had to be lifted for this medication to be administered. This medication was administered by LVN D. 04/13/23 09:13 AM -Interviewed resident #11 and she was unable to answer questions regarding receiving insulin in front of other residents. Record review of facility provided admission pack revealed the following policy Federal Resident Rights undated, revealed the following: You have the right to personal privacy and confidentiality of your personal medical records. You have the right to: personal privacy, including accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. 676010 Page 2 of 19 676010 04/14/2023 Legacy Rehabilitation and Living 4033 W 51st Ave Amarillo, TX 79109

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 2 (Resident #34, and #67) of 23 residents reviewed for advanced directives. Resident #34 and Resident #67 had a DNRs in their records that were incomplete, missing information and signatures. The facility's failure to ensure the accuracy of a residents advanced directive such as a DNR (Do Not Resuscitate), recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care could place residents a risk for not receiving healthcare as per their or their legal representatives wishes. Findings include: Resident #34 Record review of the face sheet dated 4-13-2023 in the clinical record for Resident #34 revealed a [AGE] year-old female resident admitted to the facility originally on 3-1-2019 and readmitted on [DATE] with diagnoses to include type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), dementia (a group of thinking and social symptoms that interferes with daily functioning), aphasia (loss of the ability to understand or express speech caused by brain damage), dysphasia (difficulty swallowing food or liquids arising from the throat or esophagus), pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder), and dyskinesia (abnormality or impairment of voluntary movement). Under the section Advanced Directives Resident #34 was listed as a DNR. Record review of the clinical record for Resident #34 revealed the last MDS completed was a quarterly dated 4-4-2023 with a BIMS that could not be evaluated because she is rarely/never understood, and she had a functionality of requiring one to two-person assistance with all activities. Record review of the clinical record for Resident #34 revealed a care plan with admission date of 3-28-2023 with the following: Focus: Resident has elected DNR status-Date initiated 3-30-2023 Record review of the clinical record for Resident #34 revealed an Order Summary with active orders as of 1-1-2023 with the following order: DNR-Do Not Resuscitate-Order date 11-20-2019 Record review of the clinical record for Resident #34 revealed a DNR dated 7-28-2016 (by Resident #34's legal guardian) with the following: Section-Physician Statement-there was no physicians signature, no printed physician name, no date of signature, and no printed license number. There was no information in the Directive by Two Physicians section. 676010 Page 3 of 19 676010 04/14/2023 Legacy Rehabilitation and Living 4033 W 51st Ave Amarillo, TX 79109

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Section-All person who have signed above must sign below, acknowledging that this document has been properly completed-there were no secondary signatures in this section. Resident #67 Record review of the face sheet dated 4-13-2023 in the clinical record for Resident #67 revealed a [AGE] year-old female resident admitted to the facility originally on 3-7-2021 and readmitted on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow, chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), malnutrition (lack of proper nutrition), and dysphasia (difficulty swallowing food or liquids arising from the throat or esophagus). Under the section Advanced Directives Resident #67 was listed as a DNR. Record review of the clinical record for Resident #67 revealed the last MDS completed was a quarterly dated 2-4-2023 with a BIMS of 5 indicating she was severely cognitively impaired and she and had a functionality of requiring one to two-person assistance with all activities. Section O-Special Treatment, Procedures, and Programs Resident #67 was listed as having hospice care while a resident. Record review of the clinical record for Resident #67 revealed a care plan with admission date of 8-14-2021 with the following: Focus: Resident has elected DNR status-Date initiated 12-5-2022 Focus: Resident wishes to remain in the facility long term care. Resident is a DNR. Resident is under the care of hospice. Record review of the clinical record for Resident #67 revealed an Order Summary with active orders as of 4-13-2023 with the following order: DNR-Do Not Attempt Resuscitation-Order date 12-2-2022 Record review of the clinical record for Resident #67 revealed a DNR dated 12-2-2022 (by both witnesses) with the following: Section-Declaration of the legal guardian, agent, or proxy on behalf of the adult person who is incompetent or otherwise incapable of communication-there is no date of when the legal guardian signed the DNR form. Section-Physician's Statement-there is no date of when the physician signed the DNR form. During an interview on 04-13-2023 at 02:26 PM LVN D confirmed she was responsible for Resident #34 and #67 during the shift. LVN D reported that she had been employed for this facility for awhile and she was aware that both Resident #34 and #67 were currently a DNR status. LVN D reported that Resident #67 was on hospice and was a DNR, that if Resident #67 coded she would not start CPR, and she would notify Hospice. She reported that Resident #34 was a DNR and if Resident #34 coded she would not start CPR, she would notify the DON or ADON, notify family, and call the funeral home. LVN D pulled 676010 Page 4 of 19 676010 04/14/2023 Legacy Rehabilitation and Living 4033 W 51st Ave Amarillo, TX 79109

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few up both residents DNR forms on the computer system. She verified by their face sheet that Residents #34 and #67 were listed as a DNR. LVN D then reviewed each resident's DNR form. LVN D reported that Resident #67's physician and legal guardian did not date the DNR form. Resident #34's did not have any physician's information to include the signature, date, printed signature, and license number, and there were no secondary signatures for any persons who signed the DNR form. When questioned LVN D reported that both Resident #34 and #67's forms were not correct and therefore invalid and that if Resident #34 and/or #67 coded then she would start CPR. LVN D reported that if the DNR forms are not correct the resident's wishes will not be followed. During an interview on 04-13-2023 at 02:39 PM the DON and RN A (Resource Nurse) reviewed Resident #34 and #67's DNR forms and verified that Resident #67 was missing the date of when the physician and legal guardian signed the forms and Resident #34 was missing the physician information and all the secondary signatures. They verified that the DNR forms were invalid. The DON reported that the Social Worker was responsible for ensuring DNR accuracy and that the Social Worker was a new employee and had not had time to be trained on the DNR process. The DON reported that if the DNR's were not filled out correctly then staff will not fallow the DNR process correctly and the residents wishes would not be followed. Both the DON and RN A reported that they would immediately start an in-service with staff and ensure that the two DNR's were corrected. The DON and RN A reported that at all Case Conference meetings each resident was asked if they wished to continue to be a DNR, but the DNR form was not reviewed. The DON reported that they will start pulling the DNR form and review the form at the Case Conference to ensure that it is complete and accurate. Record review of facility provided policy titled Advanced Directive Documentation, revised 12-2019, revealed the following: Documentation: Policy: 4. Ensure compliance with OBRA and State Law respecting Advance Directives. Record review of OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES, undated revealed the following: -The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professional 676010 Page 5 of 19 676010 04/14/2023 Legacy Rehabilitation and Living 4033 W 51st Ave Amarillo, TX 79109

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to conduct a comprehensive and accurate assessment of each resident using the resident assessment instrument (RAI) specified by CMS for 2 (Resident #58 and #79) of 23 residents whose records were reviewed for assessments. Resident #58 and Resident #79 did not have section C completed on their last MDS assessment. This failure to ensure comprehensive and accurate assessments could affect all residents by placing them at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services. Finding include: Resident #58 Record review of Resident #58's face sheet dated 4-13-2023 revealed a [AGE] year-old male resident admitted to the facility originally on 5-19-2020 and readmitted on [DATE] with diagnoses to include end stage renal disease (a medical condition in which persons kidneys cease functioning on a permanent basis leading to the need for regular course of long-term dialysis or kidney transplant), type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), malnutrition (lack of proper nutrition), congestive heart failure (a chronic condition in which the heart dose not pump blood as well as it should), and hypertension (a condition in which the foresee of the blood against the artery walls is too high). Record review of Resident #58's clinical record revealed he had an annual MDS completed 2-23-2023, a Medicare 5-day MDS completed 2-23-2023, and a Modification of MDS completed 2-23-2023. All three MDS's did not list Resident #58 with a BIMS score due to the entire section was completed with dash's indicating no information was available (for the 7-day look back period required by the RAI manual). All three MDS's listed Resident #58 with a functionality of requiring one person assistance with his activities (for the 7-day look back period required by the RAI manual). Resident #79 Record review of Resident #79's face sheet dated 4-13-2023 revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include unspecified intellectual disabilities (a diagnoses assessed due to multiple factors, such as physical disability or co-occurring mental illness), dysphasia (difficulty swallowing food or liquids arising from the throat or esophagus), hypertension (a condition in which the foresee of the blood against the artery walls is too high), gastrostomy (an opening into the stomach from the abdominal wall), and cognitive communication deficit (difficulty with thinking and how someone uses language), Record review of Resident #79's clinical record revealed he had a quarterly MDS completed 3-10-2023. The MDS did not list Resident #79 with a BIMS score due to the entire section with completed with dash's indicating no information was available (for the 7-day look back period required by the RAI manual). Resident #79 was listed with a functionality of requiring set-up assistance with activities (for the 7-day look back period required by the RAI manual). 676010 Page 6 of 19 676010 04/14/2023 Legacy Rehabilitation and Living 4033 W 51st Ave Amarillo, TX 79109

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 04-13-2023 at 1:55 pm MDS Coordinator B stated that the last MDS for Resident #58 and #79 was completed during a time when the facility did not have a social worker and the MDS BIMS score for each one was just missed. MDS Coordinator B stated that the social worker is the person who is responsible for completion of the BIMS information on the MDS. During an interview on 4-13-2023 at 2:00 pm MDS Coordinator B and MDS Coordinator C both stated that the previous social worker had just quit, and the facility was in between getting a new social worker (the new social worker started on 3-8-2023) and that the BIMS score for Resident #58 and #79 was missed. MDS Coordinator B reported that there was no reason for the BIMS to not have been completed. During an interview on 04/13/23 at 02:20 PM the Social Worker confirmed that she was responsible for completing the BIMS section of the MDS assessment and that she was hired on 3-8-2023 and was not present for Resident #58 and #79's MDS assessment. The Social Worker reported that if the MDS is not completed correctly then staff will not be aware of a resident's cognitive function and care may be affected. During an interview on 04-14-2023 at 08:16 AM MDS Coordinator B reported that the facility follows the RAI Manual for MDS accuracy. MDS Coordinator B reported that if the MDS is not accurate if can affect facility reimbursement but usually not affect resident care. Record review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17, dated October 2019 revealed the following: Section C Cognitive PatternsSECTION C: COGNITIVE PATTERNS Intent: The items in this section are intended to determine the resident's attention, orientation, and ability to register and recall new information. These items are crucial factors in many care-planning decisions. Coding Tips o If the resident interview was not conducted within the look-back period (preferably the day before or the day of) the ARD, item C0100 must be coded 1, Yes, and the standard no information code (a dash -) entered in the resident interview items. 676010 Page 7 of 19 676010 04/14/2023 Legacy Rehabilitation and Living 4033 W 51st Ave Amarillo, TX 79109

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed, based on a resident's comprehensive assessment, to ensure that a resident is offered a therapeutic diet when there is a nutritional problem, and the health care provider orders a therapeutic diet for 2 (Resident #23 and Resident #208) of 23 residents reviewed for nutrition. Residents Affected - Few Residents #23 and #208 had physician's orders for therapeutic diets, but the dietary staff did not have them listed as receiving therapeutic diets. This failure could place residents who are to receive therapeutic diets at risk of not receiving the diets as ordered and could result in health complications such as increased sugar, waste and build up in the blood stream due to inappropriate nutrition. Findings included: Record review of Resident #23's face sheet, dated 04/14/23, revealed a [AGE] year-old female admitted to the facility on [DATE] with an initial admission date of 06/20/22. She was admitted with diagnoses that included, but were not limited to, type 2 diabetes, bipolar disorder, major depressive disorder, borderline personality disorder, Parkinson's disease, and morbid obesity. Record review of Resident #23's quarterly MDS, dated [DATE], revealed a BIMS of 15 indicating her cognition was intact. She required supervision and no set up or physical help from staff in bed mobility, walking and locomotion, and toilet use. She required supervision and set up help with eating and limited to extensive one-person assistance with transfer, dressing, and personal hygiene. She was on a therapeutic diet while a resident. Record review of Resident #23's current physician's orders, dated 04/14/23, revealed an order for a CC/RCS (controlled carbs/reduced concentrated sugar) diet dated 11/08/22. Record review of Resident #208's face sheet, dated 04/13/23, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, end stage renal disease (last stage of kidney failure), type 2 diabetes, fluid overload, morbid obesity, and hypertension (high blood pressure). Record review of Resident #208's admission MDS, dated [DATE], revealed a BIMS score of 15 which indicated intact cognition. He required limited to extensive, one- to two-person assistance with bed mobility, transfer, locomotion, dressing, toilet use and personal hygiene. He was independent with eating. He was on a therapeutic diet while a resident. Record review of Resident #208's care plan, dated 03/22/23, revealed he had a potential nutritional problem related to diagnosis of fluid overload and end stage renal disease. One of the interventions listed to address the issue was diet as ordered by physician. Record review of Resident #208's current physician's orders dated 04/13/23 revealed an order for LCS Diet (low concentrated sugar) dated 03/22/23 and an order for CCHO (consistent carbohydrate for diabetes) Renal diet dated 03/29/23. 676010 Page 8 of 19 676010 04/14/2023 Legacy Rehabilitation and Living 4033 W 51st Ave Amarillo, TX 79109

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and interview on 04/13/23 at 08:27 AM Resident #208 was lying in bed on his back in a hospital gown with a blanket over his left leg and his right leg outside the blanket. He stated he needed to eat less carbohydrates because they had been causing problems with the function of his legs. He stated the facility had not been helping him with his diet. He stated, Every supper plate is ¾ potato. He stated he had been taking care of his diet on his own because if I wasn't this stay here would have been pointless. He stated he has spoken to nurses and CNA's about his diet and asked often for substitutions but he did not know which ones he had spoken to. During an observation on 04/13/23 at 12:03 PM Resident #208 was lying in bed on his back asleep. His lunch tray was next to the bed and his plate was made up of mixed carrots and peas, cheesy tater tot casserole, a slice of white bread, and a piece of cake-the regular lunch menu of the day. During an interview on 04/13/23 at 04:12 PM DS K stated the only therapeutic diet the facility did was low concentrated sugar. She stated that is the same thing as a diabetic diet. She stated some residents on special diets prefered to eat regular diets and they must honor the resident's wishes. When asked about a renal diet DS K stated the facility uses a liberal renal diet and that means not so many potatoes or carbohydrates. DS K and Dietary L produced the menu for the week and showed that the regular lunch for 04/13/23 was beefy tater tot casserole and the alternative was a turkey sandwich with tomato soup. DS K stated if a resident was on a renal diet, they would have had the sandwich and soup option. She stated the nurses gave her a communication form that reflected diet orders, and she filled out the tray cards for dietary staff to see and comply with. DS K and Dietary L provided a diet type report for all residents on special diets. Record review of the diet type report, provided by DS K and Dietary L, dated 04/13/23 for all residents on a therapeutic diet revealed no entry for Resident #23 or Resident #208. During an observation and interview on 04/14/23 at 01:18 PM Resident #23 was sitting in her wheelchair outside in the smoking courtyard having a cigarette with several other residents. She stated she got a regular diet and was not on a special diet despite being a diabetic. She stated it made it harder for her to make good choices in what to eat. She stated she has told nurses and CNA's about her diet but she did not know which nurses and CNA's she had spoken to. During an interview on 04/14/23 at 01:28 PM ADON E stated a possible negative outcome of a resident not receiving a special diet as ordered was, obviously a risk of high glucose and insulin. He stated the diets for residents are in our system (the facility's EHR). He stated the facility was working to reeducate staff on accessing that information. During an interview on 04/14/23 at 02:28 PM LVN H stated a possible negative outcome of a resident not getting the ordered special diet would be, They would have higher sugar. She stated, Our protocol with diet change is fill out a communication form and give it to the kitchen. Then we follow up for 72 hours to be sure they get it. During an interview on 04/14/23 at 02:36 PM the DON stated residents who were not following a renal diet order might get too much protein in their diet and diabetic residents not following a diabetic diet might get too much sugar in their diet. During an interview on 04/14/23 at 02:54 PM the DON and RN A stated the nurses were responsible for filling out the dietary communication form and turning it into the kitchen. 676010 Page 9 of 19 676010 04/14/2023 Legacy Rehabilitation and Living 4033 W 51st Ave Amarillo, TX 79109

F 0692 Record review of an undated facility policy titled; Therapeutic Diets revealed the following: Level of Harm - Minimal harm or potential for actual harm Policy: Residents Affected - Few When necessary, the facility will provide a therapeutic diet that is individualized to meet the clinical needs and desires of a patient/resident to achieve outcomes/goals of care. Procedure: . 3. Diets will be offered as ordered by the physician or designee. 8. An individual's medical record and diet on file in the food and nutrition service office's system must be reviewed on a regular basis to assure that they agree. 676010 Page 10 of 19 676010 04/14/2023 Legacy Rehabilitation and Living 4033 W 51st Ave Amarillo, TX 79109

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences, for 1 (Resident #208) of 23 residents reviewed for respiratory care. Residents Affected - Few Resident #208 had orders for oxygen at 2 liters per minute and was receiving oxygen at higher concentrations. This failure could place residents who receive oxygen at an increased risk for receiving oxygen at the wrong rate which could lead to hypercapnia (too much carbon dioxide in the blood), pulmonary oxygen toxicity (damage to the lung lining tissues and air sacs), hypoxemia (low levels of oxygen in the blood, decreasing the oxygen supply to vital organs), and shortness of breath. Findings included: Record review of Resident #208's face sheet, dated 04/13/23 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, end stage renal disease (last stage of kidney failure), type 2 diabetes, and hypertension (high blood pressure). Record review of Resident #208's admission MDS, dated [DATE], revealed a BIMS score of 15 which indicated intact cognition. He required limited to extensive, one- to two-person assistance with bed mobility, transfer, locomotion, dressing, toilet use and personal hygiene. He was independent with eating. The MDS documented a need for oxygen while not a resident and as a resident. Record review of Resident #208's care plan, dated 03/22/23, revealed he had oxygen therapy related to congestive heart failure at 2 liters per minute continuously by nasal cannula. One of the interventions listed on the care plan was to give medications as ordered by physician. Record review of Resident #208's current physician's orders dated 04/13/23 revealed an order for oxygen at 2 liters per minute continuous per nasal cannula. The order had a start date of 03/23/23. Record review of Resident #208's oxygen saturation summary dated 04/13/23 revealed his oxygen saturation was checked and documented on 04/12/23 at 09:23 AM and 08:34 PM. His oxygen saturation was checked and documented by nursing staff one to two times a day for each day he was in the facility except 03/22/23. During an observation on 04/12/23 at 08:22 AM Resident #208 was lying in bed on his back asleep with oxygen by nasal cannula at 4 liters per minute. During an observation on 04/13/23 at 08:27 AM Resident #208 was lying in bed on his back asleep with oxygen by nasal cannula at 4 liters per minute. During an observation on 04/13/23 at 11:02 AM Resident #208 was lying in bed on his back asleep with oxygen by nasal cannula at 4 liters per minute. During an observation on 04/13/23 at 12:03 PM Resident #208 was lying in bed on his back asleep 676010 Page 11 of 19 676010 04/14/2023 Legacy Rehabilitation and Living 4033 W 51st Ave Amarillo, TX 79109

F 0695 with oxygen by nasal cannula at 4 liters per minute. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 04/14/23 at 09:28 AM Resident #208 was sitting in his w/c with his hospital gown on and his oxygen at 3 liters per minute. He stated he took oxygen by nasal cannula all day long. He stated he could not remember when he started taking oxygen. Residents Affected - Few During an observation and interview on 04/14/23 at 09:45 Resident #208 stated he did not turn his own oxygen up. He said, A nurse did that. Resident's oxygen was at 3 liters per minute. During an interview on 04/14/23 at 10:38 AM LVN G stated the nurses knew what level of oxygen a resident needed because it is in the order itself and we get it in report at change of shift. She stated, We review the orders with the provider before putting them in the chart. When asked how she knew a resident's oxygen is set at the correct level she said the nurses look at them every time we go in the room, and when we monitor oxygen levels. She stated if a resident took more oxygen than was ordered it could lead to overloading lungs, lungs can't tolerate that high amount of oxygen. It can be toxic because carbon dioxide can't exchange fast enough. Too much oxygen can be just as bad as not having oxygen. During an interview on 04/14/23 at 11:00 AM LVN G stated she worked on Resident #208's hall. She stated she thought Resident #208's oxygen was supposed to be set at 3-4 liters per minute. She looked up the order and noted it was for 2 liters per minute. During an interview on 04/14/23 at 01:06 PM ADON E stated a negative outcome of using more oxygen than ordered was there is always a danger if not following physicians orders. During an interview on 04/14/23 at 02:28 PM LVN H stated a negative outcome of not using oxygen as ordered was carbon dioxide levels and labs can get messed up. During an interview on 04/14/23 at 02:38 PM the DON stated a negative outcome of not using oxygen as ordered was oxygen dependance, or not enough oxygen or cardiac arrest. During an interview on 04/14/23 at 02:54 PM the DON and RN A stated the nurses were responsible for entering oxygen orders into the electronic health record and for making sure the orders were followed. Record review of facility policy titled, Policy/Procedure - Nursing Clinical and dated 05/2007 revealed the following: Subject: Physician Orders . 1. No drugs or biologicals shall be administered except upon the order of a person lawfully authorized to prescribe for and treat human illnesses. 676010 Page 12 of 19 676010 04/14/2023 Legacy Rehabilitation and Living 4033 W 51st Ave Amarillo, TX 79109

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 3 of 3 medications. Omeprazpole, Vitamin D3 5000IU, and Dronabinol The facility failed to ensure that medications have an expiration date and/or are discarded appropriately and in a timely manner after medication has expired. This failure could place residents at risk for reduced efficacy of the medications administered. Findings include: [DATE] 9:09 AM-Observation and interview with LVN D stated that she had medications to give to Resident #56. Vitamin D3 5000IU was expired and given to Resident #56. LVN D stated that the iron was expired and removed it from the drawer however the iron did not expire until 12/2023. LVN D did not remove iron and or the actual expired medication of Vitamin D3 was crushed and administered to Resident #56. LVN D did perform hand hygiene before and after medication was administered. LVN D proceeded to remove the iron stating that it was expired and would replace it. LVN D stated that she saw this documentation on my medication pass documentation form. However, she did not remove it from the resident #56 medication before crushing the medication and administering it to the Resident #56. The iron is not what is expired, it is the Vitamin D3 5000IU, with an expiration date of [DATE]. [DATE] 10:56 AM-observed medication within the lock box placed in the fridge in station #3 medication room. Medication was for resident #19, medication Dronabinol 2.5mg no expiration date found on label. When LVN D was asked if medication was given today, she confirmed that medication was given before meals to help with appetite. Confirmed a 2nd time with LVN D that medication had been given today, and LVN D stated yes that Resident #19 had received this medication. [DATE] 08:02 AM-observed medication Omeprazole tablet 20mg was given to Resident #3, there is no expiration noted on the over-the-counter medication. The expiration date was removed from the box when box was opened, and no expiration date was found on medication box. Medication was administered by CMA F to Resident #3. [DATE] 09:02 AM -interviewed ADON E what was the protocol on expired meds. He stated that expired medication should be pulled from carts and discarded and destroyed upon discovery. [DATE] 09:07 AM -interviewed MA F what was the protocol on expired meds. She stated that she makes her nurse aware when an expired medication is discovered. Record review of facility provided policy titled, Storing and controlling medications policy stated that Medications that are discontinued, expired, contaminated, or deteriorated, and those that are in containers that are cracked, soiled, or without secure closures are immediately removed from the locked medication storage area and disposed of in accordance with the Facility policies and procedures. 676010 Page 13 of 19 676010 04/14/2023 Legacy Rehabilitation and Living 4033 W 51st Ave Amarillo, TX 79109

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in the facility kitchen reviewed for dietary services in that: Residents Affected - Many There was unlabeled, undated, and unsealed food in the refrigerators, freezers, and dry storage area; there was expired food in the refrigerators, freezer, and dry storage area; staff's personal food was in one of the service refrigerators; and refrigerator and freezer temperature logs were not updated. These failures placed residents who ate food served by the kitchen at risk for food-borne illness. Findings include: In an observation of the kitchen and refrigerator on 4/12/23 at 8:10 AM the following was observed: 1. The main trash can in the kitchen, had no cover and contained discarded food items. 2. The foods in the main refrigerator(s) were not labeled or dated with the contents of the containers, nor the received on, opened on or expiration dates; signs posted on all refrigerators, freezers, and pantry doors, clearly stated, All foods in walk-in and reach-in need a date in and a date out. 3. 24 individual cartons of Ensure, nutritional supplement drink, with an expiration date of 3/1/23. 4. 2 food service containers of orange juice, with no date. 5. 4 food service containers of apple juice, with no date. 6. 24 individual glasses of fruit punch, covered, with no date. 7. 1 12-pound container of Three Bean Salad, with no date. 8. 676010 Page 14 of 19 676010 04/14/2023 Legacy Rehabilitation and Living 4033 W 51st Ave Amarillo, TX 79109

F 0812 1 dozen eggs, with no date. Level of Harm - Minimal harm or potential for actual harm 9. 1 quart of gravy, with no date. Residents Affected - Many 10. 1 food service container of melted butter, with no date. 11. 3 banana cream pies, with no date. 12. Temperature logs on the holding refrigerator, walk-in cooler and the freezer had not been updated since 4/10/23. 13. 1 large zip top bag of tortilla quarters, open to air, with no date. 14. 2 food service packages of tortillas, open to air/, with no date. 15. 8 slices of cooked bacon in a zip top bag, with no date. In an observation of the walk-in freezer on 4/12/23 at 8:29 AM, the following was observed: 1. 24 1-pound rolls of sausage, with an expiration date of 12/9/22. 2. 1 large food service bag of shredded cheddar cheese, open to the air, with no date. In an observation of the walk-in pantry on 4/12/23 at 8:42 AM, the following was observed: 1. 1 28-ounce box of Cream of Wheat, open to air, with no date. 2. 676010 Page 15 of 19 676010 04/14/2023 Legacy Rehabilitation and Living 4033 W 51st Ave Amarillo, TX 79109

F 0812 1 large food service container of peanut butter with an expiration date of 10/14/23. Level of Harm - Minimal harm or potential for actual harm 3. 1 large zip top bag of penne pasta, open to air, with no date. Residents Affected - Many 4. 1 10-pound bag of dry spaghetti, open to air, with no date. In an interview on 4/6/23 at 1:30 PM, the Dietary Manager stated all foods were to be labeled and dated and were to be used in a first in, first out manner. She also stated that all foods were to be clearly marked with the contents and date opened. When asked why foods were not sealed properly and were left open to air, she stated that all food items, regardless of whether they are in the pantry, refrigerator or freezer should be sealed tightly to avoid spoilage, contamination and/or freezer burn. When asked how long foods that were opened should be kept in the refrigerator, she stated that their policy was to throw leftovers out after 7 days. In an interview on 4/6/23 at 4:09PM, dietary worker M and dietary worker N were asked what the consequences of serving expired food to the residents would be, Dietary Worker M stated, We could get written up! Dietary Worker N immediately stated that the residents could become sick, and all other workers agreed. A review of the facility's Dietary Services Policy and Procedures book revealed the following: 1. The facility will store, prepare, distribute, and serve food under sanitary conditions. 2. Foods placed in the freezer are to be left in the original wrapping with an identifying label. If an item must be rewrapped, a moisture proof wrapping or closed container should be used to prevent freezer burn. 3. Leftovers will be stored in a container or wrapped carefully and securely. Each item will be clearly marked, labeled, and dated before being refrigerated. Leftover food is to be used within 7 days or discarded. A review of the FDA Food Code 2017 revealed the following: 3_201.11 (C) PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under §§ 3-202.17 and 3-202.18. Pf A review of the Food Storage Policy and Procedure revealed the following: 676010 Page 16 of 19 676010 04/14/2023 Legacy Rehabilitation and Living 4033 W 51st Ave Amarillo, TX 79109

F 0812 Refrigerated food storage: Level of Harm - Minimal harm or potential for actual harm 1. Residents Affected - Many TCS food must be maintained at or below 41 degrees F unless otherwise specified by law. Periodically take temperatures of refrigerated foods to assure temperatures are maintained at or below 41 degrees F. Temperatures for refrigerators should be between 35-41 degrees F. Thermometers should be checked at least two times each day. Check for proper functioning of the unit at the same time. 2. All foods should be covered, labeled, and dated. All foods will be checked at assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable) or discarded. 3. Refrigerated food should be stored upon delivery and careful rotation procedures should be followed. Frozen Foods: 1. Frozen foods must be maintained at a temperature to keep the food frozen solid. Freezer temperatures should be checked at least two times each day. Check for proper functioning of the unit at the same time. Periodically, check the firmness of foods in the freezer to assure temperatures are maintained to keep food frozen solid. 2. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. 3. All food items should be stored upon delivery and careful rotation procedures should be followed. 676010 Page 17 of 19 676010 04/14/2023 Legacy Rehabilitation and Living 4033 W 51st Ave Amarillo, TX 79109

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 staff (CNA I, CNA J, and MA F) reviewed for infection control. Residents Affected - Some The facility failed to ensure that CNA I, CNA J, and MA F performed hand hygiene appropriately during overall care of residents, this including medication pass. This failure could place the residents at an increased risk for potentially exposing them to viral infections, secondary infections, tissue breakdown, communicable diseases and feelings of isolation related to poor hygiene. The findings include: 04/12/23 10:03 AM-observed incontinent performed by CNA I and CNA J proceeded to performed incontinent care on resident #61. CNA J performed hand hygiene and donned clean gloves. CNA I did not perform hand hygiene before donning gloves. Resident #61 was seating in a chair in the shower room removing clothing. Resident #61 could do this alone and needed not assistance. Resident #61 was asked if she would like to take a shower and she refused. CNA I asked if resident would sign a refusal sheet. Resident #61 stated that she would sign the document. Resident #61 was then asked if she could stand so that peri-care could be performed. CNA J performed peri-care while standing behind the resident. CNA J wiped from front to back of resident. Wipe was discarded, another wipe was obtained and applied from front to back on resident. No peri-care was performed to the front of the resident's genital area. Resident sat on a towel that had been laid in the chair, a clean brief, and clean pants by CNA J without hand hygiene performed or removing of dirty gloves were provided to resident to put on. Hand hygiene was encouraged to resident by CNA I, who assisted resident with hand hygiene. 04/12/23 10:11 AM-observed incontinent care performed by CNA I with Resident #45. No hand hygiene was performed before starting peri-care. Soiled clothing and brief were removed by CNA I. There was no hand hygiene or glove change before peri-care was performed. CNA I performed peri-care starting at the back of the resident and performing peri-care to genitals last. No hand hygiene or glove change was performed before clean brief or clothing was placed on Resident #45. 04/12/23 10:19 AM- observed incontinent care performed by CNA I and CAN J. Resident #19. Resident #19 was wheeled into the shower room; CNA I did not perform hand hygiene before donning gloves to place a gait belt around resident. Resident #19 was assisted to a standing position form her chair. CNA J did not perform hand hygiene before donning gloves. CNA J proceeded to remove residents' pants and brief, while CNA I helped resident to stand. Peri-care was performed with peri wipes, buttocks and rectal area cleaned with wipes. No observation of female genital area being cleansed. No hand hygiene or glove change was performed before clean brief or clothing was placed on resident, by either CNA I or CNA J. 04/12/23 11:22 AM -Interview with CNA J was asked what the protocol for incontinent care for resident is, CNA J stated that she would wash hands before and after incontinent care. However, there was no mention of hand hygiene or change of gloves in between performing removal of soiled clothes or brief and placing clean brief and clean clothes. CNA J stated that any new skin issues or bruises are placed on a shower sheet and reported to LVN. 676010 Page 18 of 19 676010 04/14/2023 Legacy Rehabilitation and Living 4033 W 51st Ave Amarillo, TX 79109

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 04/12/23 11:32 AM -Interview with CNA I stated all new bruises or skin issues are documented on shower sheets and reported to LVN on duty. CNA I was asked what the protocol was for incontinent care. CNA I stated that dirty soiled clothing and briefs will be discarded in dirty laundry. Doffing of dirty gloves, and hand hygiene performed before new gloves will be put on before perineal care is performed. When surveyor asked CNA I why she did not perform hand hygiene, CNA I stated that she did not have an answer. When asked what the negative outcome from lack of clean gloves and proper hand hygiene could be, CNA I stated, it is a break in infections control. 04/13/23 08:02 AM -observed MA F taking medication from a pill blister pack and dropping medication into her hand and then placing into medication cup. Let MA F know that medication pass observation was going to be performed. No hand hygiene was performed before, during, or after medication administration to Resident #3. Record review of infection control/hand hygiene-policy states that hand hygiene will be performed hand hygiene before preparing or handling medications. Hand hygiene will also be performed before and after the donning and doffing of gloves before moving from a contaminated body site to a clean body site during resident care. After reviewing handwashing check-offs CNA I, CNA J, MA F checkoffs were not found. Record review of a facility provided policy titled, Hand Hygiene, dated 05/2007, revealed, in part, B. Before and after direct contact with resident, C. Before preparing or handling medications .H. Before moving from a contaminated body site to a clean body site during resident care; I. After contact with a resident's intact skin; J. After contact with blood or bodily fluids. Record review of a facility provided policy titled, Infection Prevention and control Program, dated 06/2021, revealed, in part, .3. The facility personnel will conduct themselves and provide care in a way that minimizes the spread of infection . b. Facility personnel will wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice . 676010 Page 19 of 19