Health inspection·January 21, 2026

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resistant to oxygen use or removing her NC. The following notes were revealed:A note by LVN B on 11/18/25 at 05:00 PM which read, Patient found by CNA on the floor in her room. Patient lying on right side next to the bed. Patient reports she was trying to get help and was going to crawl out of here. Head to toe assessment completed. All neuro's intact to baseline. Patient denies hitting her head. O2 90% on room air.During an interview on 01/21/26 at 11:32 AM LVN B stated Resident #1 often had confusion and low oxygen levels when she was living in the facility.During an interview on 01/21/26 at 03:07 PM Resident #1's family member A stated he visited Resident #1 at the facility on 11/18/25 and fed her a dinner of barbeque. He stated he was with her for approximately an hour and a half and she did not have her oxygen on at any time during his visit. He stated she was seated in her wheelchair near the nurses' station on hall 100 and he was standing next to her for the visit. He stated he called Resident #1's family member B on a facetime call during a portion of his visit.During an interview on 01/21/26 at 03:10 PM Resident #1's family member B stated she was on a facetime call with Resident #1's family member A and Resident #1 on 11/18/25. She stated she took several screenshots of Resident #1 during the call.Record review of time stamps of 15 photographs sent by Resident #1's family member B revealed they were taken on 11/18/25 with times ranging from 05:31 PM to 06:14 PM.During an interview on 01/21/26 at 03:41 PM ADON stated if a resident had orders for continuous oxygen, they should not take it off to eat. She stated taking off oxygen that was ordered for continuous use could cause a resident to become hypoxic (low levels of oxygen in the body tissues which can result in confusion, bluish skin, and changes in breathing and heart rate), not have enough air, not be able to talk, pass out.During an interview on 01/21/26 at 04:11 PM RN C stated a resident with orders for continuous oxygen should not take the oxygen off at any time. She stated, Sometimes they (residents) will (take it off) and we (nursing staff) will encourage them to put it back on. RN C stated a possible negative outcome of a resident not receiving oxygen continuously as ordered was their oxygen saturation could drop and cause lightheadedness, dizziness . a lack of oxygen to the brain.During an interview on 01/21/26 at 04:34 PM OM stated a resident who had orders for continuous oxygen might be negatively affected if they did not receive oxygen for an hour or two. He stated, It kinda depends on the patient. If they're ordered continuous (oxygen) and take it off themselves, we can't force it. We should chart about it and put interventions in place if that is an issue with that resident.During an interview on 01/21/26 at 05:37 PM LVN A stated a resident with orders for continuous oxygen should not take the oxygen off at any time. She stated, If they take if off themselves, we chart it and monitor their sats (oxygen saturation levels) to be sure their oxygen stays within normal limits. LVN A stated a resident could become cyanotic (blue or purple discoloration of skin due to poor blood circulation or low oxygen levels) and they can get dizzy if they were not receiving oxygen as ordered. During an interview on 01/21/26 at 05:40 PM DON stated a resident could do whatever they want with their oxygen. She stated, It is their right. We encourage them not to (take oxygen off if it is ordered continuously), but that is all we can do. She stated a resident with orders for continuous oxygen going a few hours without oxygen might or might not be negatively affected. She stated, It is a case-by-case basis.Record review of an undated facility policy titled Oxygen therapy policy revealed the following: . Oxygen is considered a drug and must be prescribed by an authorized clinician.Record review of facility policy titled Administration of Medications and dated 7/2017 revealed the following: . It is the policy of this Facility, medication shall be administered as prescribed by the resident's physician, nurse practitioner, or physician's assistant. 2. Medications must be given in accordance with the resident's service plan. 3. Medications must be administered in accordance with the written orders of the attending physician. 10. Should a drug be . refused . the staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676010 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 676010 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/21/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy Rehabilitation and Living 4033 W 51st Ave Amarillo, TX 79109 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 administering must indicate the reason on the MAR. For those utilizing eMARs, the appropriate code must be entered with any follow up documentation as appropriate for the situation. 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: 676010 If continuation sheet Page 3 of 3