Health inspection·June 10, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm elected Hospice Care. Interventions included review residents/responsible agent related to end-of-life care and processes dated 05/16/22. Record review of Resident #104's care plans last revised on 05/16/22 indicated no care plans developed to address advance directives. Residents Affected - Some Observation and interview with Resident #104 on 06/07/22 at 2:44 pm revealed Resident #104 in her room in wheelchair, alert and reading a newspaper. Resident #104 said she was on hospice care. Interview on 06/09/22 at 9:03 am with MDS A revealed he was responsible for developing and updating the care plans. MDS A said he had missed developing a care plan for focus areas of advance directives for Resident # 104. Resident #104's advance directives were for DNR. MDS A said he should have developed a care plan for Resident #104 that addressed her advance directives. MDS A said there was a difference in the interventions for the care plans that addressed advance directives of Full Code or DNR. 2) Record review of Resident #45's admission record dated 06/09/22 indicated Resident #45 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident # 45's diagnoses included anemia, collapsed vertebra, disorders of bone density and structure, palpitations, and dementia without behavioral disturbance and advance directives was DNR. Record review of Resident #45's quarterly MDS dated [DATE] indicated Resident #45: -cognitive status was moderate impairment. -required limited assistance with one person for bed mobility and dressing. -required extensive assistance with one person for transfers and toilet use. Record review of Resident # 45's care plans dated 05/23/22 indicated a care plan Resident displays disruptive behaviors. Interventions included administer my behavior medications as ordered by my physician, dated 05/23/22. Record review of Resident #45's care plans last revised on 06/07/22 indicated no care plans developed to address advance directives. Observation and interview with Resident # 45 on 06/08/22 at 1:37 pm revealed Resident #45 in her room in bed. Resident #45 said she did not remember how she had fallen but did not get hurt. Interview on 06/09/22 at 9:03 am with MDS A revealed he was responsible for developing and updating the care plans. MDS A said he had missed developing a care plan for focus areas of advance directives for Resident #45. Resident #45's advance directives were for DNR. MDS A said he should have developed a care plan for Resident #45 that addressed her advance directives. 3) Record review of Resident #4's admission record dated 06/09/22 indicated Resident #4 was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4's diagnoses included alzheimer's disease with late onset, supraventricular tachycardia (fast heartbeat) and hypertension and advance directives was full code. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 2 of 11 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 676174 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy Nursing and Rehabilitation 2202 N Travis Ave Cameron, TX 76520 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 0656 Record review of Resident #4's admission MDS dated [DATE] indicated Resident #4: Level of Harm - Minimal harm or potential for actual harm -cognitive status was moderate impairment. Residents Affected - Some -required supervision with set up only for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. -wandering-impact was not indicated. Record review of Resident #4's care plans dated 05/23/22 indicated a care plan Resident is unable to participate in my usual activities. Interventions included offer rides in the wheelchair or assistance with outdoors when weather permits. Record review of Resident #4's care plans last revised on 06/07/22 indicated no care plans developed to address advance directives and a wander guard. Record review of Resident #4's Physician Orders dated 05/10/22 indicated advance directive orders for Full Code. Review of Resident #4's Physician orders indicated no orders for wander guard. Observation and interview with Resident #4 on 06/08/22 at 9:15 a.m. revealed Resident #4 in her room in bed, wearing a wander guard on her ankle. Resident #4 said she did not know why she was wearing an ankle bracelet (wander guard). Resident #4 said she thought the wander guard bracelet on her ankle was to warn someone she had fallen. Interview on 06/09/22 at 9:06 am with MDS A revealed he was responsible for developing and updating the care plans. MDS A said he had missed developing a care plan for focus areas of advance directives for Resident #4. Resident #45's advance directives were for Full Code. MDS A said he should have developed a care plan for Resident #4 that addressed her advance directives. MDS A said he had not developed a care plan to address the use of a wander guard for Resident #4 because there was no order for a wander guard for this resident. Interview on 06/09/22 at 9:18 am with the DON revealed Resident #4 had no orders for a wander guard and she could not find any documentation of when or who placed the wander guard on Resident #4. The DON said when the resident was initially admitted , the resident was anxious and was wandering into other resident rooms. The DON said there was no care plan developed for Resident #4's advance directives or for the wander guard. Interview on 06/09/22 at 11:43 am with the DON revealed she had conducted a Wandering Risk Assessment for Resident #4 on 06/09/22 at about 10:00 am and the assessment results indicated Resident #4 was not a risk for eloping or wandering. The DON said the wander guard on Resident #4 had been removed after the assessment conducted earlier in the morning. Interview on 06/10/22 at 8:15 am with LVN B revealed a care plan was used to verify which care to provide each resident. The care plan was used to communicate to the direct care staff the interventions to be implemented for each individual resident. The advance directives interventions differed if the code status was full code or DNR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 3 of 11 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 676174 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy Nursing and Rehabilitation 2202 N Travis Ave Cameron, TX 76520 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the Wandering Risk Assessment for Resident #4 dated 06/09/22 indicated Resident #4 was not at risk for eloping or wandering. Interview on 06/09/22 at 3:45 pm with the Administrator revealed an assessment was not completed as needed to determine if Resident #4 was at risk of wandering and needed a wander guard. The staff did not catch the need to complete the assessment. The wander guard should have been care planned. Interview on 06/10/22 at 8:45 am with the DON revealed not developing care plans for advance directives placed residents at risk from staff not having the information available to them when an acute status occurred. Record review of the facility policy titled Care Planning Policy and Procedure undated indicated. Each resident's care plan will remain current and inform staff of resident's needs, strengths, goals, and approaches. Resident's care plan will be updated quarterly and as needed. Record review of the facility policy titled Advance Directives Policy and Procedure undated indicated. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. 4) Resident # 26's targeted review date for care plan update was 5/22/2022. The care plan was not updated as of 3 PM on 6/9/2022. Record review of resident # 26's diagnosis indicates an acute infection UTI ENTEROCOLITIS DUE TO CLOSTRIDIUM DIFFICILE, NOT SPECIFIED AS RECURRENT on 6/2/2022. Record review of resident #26's care plan reveals it was initiated on 2/22/2022 with a review date of 5/22/2022. Care plan reviewed for resident #26 on 6/9/22 and found to be overdue. No care plan developed for acute UTI with Clostridium Difficile and no care plan developed for isolation. Observation of resident on 6/8/2022 and 6/9/2022 found the resident in his room, by himself, sitting in a chair facing a television. A sign on his door indicated he was on isolation precautions and PPE was required to enter his room. PPE was available immediately outside his room. 6/9/2022 @ 1:00 PM interview with resident #26. He stated he could not hear me or the television. He requested I remove my mask, which I refused. 6/9/2022 @ 2:00 PM interview with MDS coordinator. He states he is aware the care plan is overdue and will get to it today. 6/9/2022 @ 2:55 PM interview with Director of Nursing: She stated a care plan should have been developed for isolation and for acute UTI with C-Dif. 6/9/2022 @ 3:50 PM interview with DON: I admit we are behind on care plans. You're right, it wasn't on the care plan. She states a care plan should have been developed for isolation and also for acute C-Dif uti. I have to ask him what the procedure is for developing new care plans for acute situations, as well a corporate. I know they are helping him care planning. Corporate nurses are training (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 4 of 11 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 676174 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy Nursing and Rehabilitation 2202 N Travis Ave Cameron, TX 76520 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 0656 Level of Harm - Minimal harm or potential for actual harm him, but I don't know how often. I need to see if I need to get in there and help him. I am able to look at the dashboard for care plans. He assured me he was working on those care plans that were overdue. I am aware of care plans that are overdue. Corporate knows what is past due. They have access to everything we do. They get with him one on one. Without me. I will say this: they e-mail me to let me know what they're working on. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 5 of 11 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 676174 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy Nursing and Rehabilitation 2202 N Travis Ave Cameron, TX 76520 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 store drugs and biologicals under proper temperature controls in three of three medication refrigerators. Both medication refrigerator logs in the facility were missing documentation, safe temperature ranges, times, and the correct refrigerator log on which to document daily monitoring. This failure could place residents at risk for adverse medication reactions, as medications can be altered by improper temperature, light, or humidity. Findings were: Record review of the daily temperature log of the south medication refrigerator log was missing documentation: 25 days in April, and 13 days in May. January, February, and March 2022 were missing altogether. Record review of the daily temperature log of the north medication refrigerator log was missing documentation: 1 day in Feb, 3 days in Mar, 8 days in April, and 3 days in May. Observation of the thermometer on 6/9/22 at 11:25 am in the north medication refrigerator revealed it was inoperable, rendering questionable documentation of the documented refrigerator temperatures. Observation of the medication dispensing machine refrigerator on 6/9/22 at 11:15 am in the north medication room revealed it had an internal temperature feature that displayed its temperature on the main screen when pressed. However, there was not a log kept for this medication refrigerator that was used for dispensing insulin, nor a manual thermometer inside it. When the temperature was checked, it displayed -3C and 26F. During an interview with DON and IP on 6/9/22 at 11:20 am, both said freezing temperatures were not acceptable for insulin and could alter the medication, rendering it unsafe for use. They immediately notified the medication dispenser company for direction and/or instruction for calbration. During an interview with DON, and IP on 6/9/22 at 11:30 am, both said they do not know how long the thermometer had not been working nor why there was so much missing documentation in the north medication room refrigerator. The DON said it was ultimately her responsibility to monitor the refrigerator logs. During an interview with AA on 6/10/22 at 9:00 am, a refrigerator temperature log template was produced by AA stating, this is the one they're supposed to be using. The header read refrigerator temperature log in capital letters with spaces for month/year, temperature ranges for both the refrigerator and freezer, and instructions that read, record temperature, time, and initial at least once per day. The body of the log had columns for the day of the month, time, fridge temp, freezer temp, and initials. AA did not know why the proper temperature logs were not in use and was unsure of whose responsibility it was to check them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 6 of 11 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 676174 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy Nursing and Rehabilitation 2202 N Travis Ave Cameron, TX 76520 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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, distribute and serve food in accordance with professional standards for food service safety and follow proper sanitation practices for 1 of 1 facility reviewed. There was no cleaning schedule, no soap or paper towels in the wall dispensers for hand washing, no hairnets available, expired food and beverage in the nutrition room refrigerators and freezers, as well as incomplete and missing nutrition room refrigerator and freezer logs, and contaminated and/or broken equipment. This failure could place residents at serious risk for complications from food contamination. Findings were: During an interview with DM during the initial tour of the kitchen on 6/7/22 at 11:25 am revealed she was new to the position (was not certified-starts classes in Sept.) and noticed issues with some of the equipment and a problem with cleaning. She said she did not know where the emergency food and water supplies were kept. She said the ice machine needed to be replaced because it was always going out. She said the blenders needed replacing because they no longer worked. She said the freezer is out of commission and the facility had a deal with the high school down the street to use their freezer. She said the soup stove had never worked. She said the process to get things fixed was for her to take it to HR, (which she said she does) who was also the director of maintenance and he would either do what he could or take it up the chain to the corporate maintenance director, who was unavailable this week due to him being on a retreat. She said all she can do after reporting the issues is wait for them (HR/corporate) to resolve them, because they're the ones who write the checks. Observation of kitchen during the initial tour on 6/7/22 at 11:25 am revealed: no hairnets available, no soap in all soap dispensers-there was a store-bought pump style in the restroom. There were no paper towels. The staff was using ABHR (alcohol-based hand rub). There was a thick, heavy build-up of a dark sticky substance covering the bottom of a shelf above the steamer table where food was being held for lunch service. Tiny dark insects were flying there. There were 2 insulated warmer carts, not in use per DM, stored in the kitchen and they were visibly filthy with streaks of a dried brown substance on the outside of one, and the other had clumps of an unknown substance on the inside bottom. The ice machine panel had been on top of the ice machine x3 days, leaving the ice exposed to the air and possible contaminants, according to DM, and was supposed to be replaced on 6/8/22. Dented pots & pans-one to the point of being unsafe due to a rounded bottom, which places kitchen staff at risk for tipping with scalding contents. Debris was seen in the bottom of the commercial mixer bowl, which was also in disrepair (the attachments would not come off the spindle making it impossible to clean.) There was a 36-gallon soup stove that had not worked in over a year and had only been used as a griddle. The juice gun tip and holder had a thick build-up of a sticky gel-like substance. Everything in the kitchen had a sticky feel to it. The washer log and the 3-compartment sink log were missing months of documentation. During an interview with DA B, [NAME] A, and DM on 6/7/22 at 11:35 am: They all said they did not know why there was no soap or paper towels-just that housekeeping is supposed to take care of that. None of them had made efforts to notify housekeeping of the situation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 7 of 11 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 676174 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy Nursing and Rehabilitation 2202 N Travis Ave Cameron, TX 76520 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Observation of CNA A during dining duty on 6/8/22 at 11:00 am: she came out of the kitchen without a hairnet. There was no signage on the kitchen doors to indicate hairnets were required. During an interview with CNA A on 6/8/22 at 11:00 am: she said she was just popping in for a sec. She said she was unaware hairnets were required for entrance to the kitchen. When showing the sign on the kitchen door that read, authorized personnel only, she did not understand she was not considered authorized dietary personnel. During an interview with DM on 6/8/22 at 11:02 am, she said the regular staff was constantly coming in & out of the kitchen without hairnets to grab something to eat or to get ice even though she tells them again and again not to. She also said maintenance was rinsing off the ice in the open ice machine to use in the coolers last night that was used to replenish the evening beverages for the residents. Observation of the ice machine in the kitchen on 6/8/22 at 11:02 am: the ice machine was still plugged in and running with ice in the bin and still exposed to the air with the front panel on top of the machine. Interview with IP on 6/9/22 at 11:17 am: she said if one piece of ice is contaminated, they're all contaminated-you can't just rinse it off. Observation of the north nutrition room and refrigerator on 6/9/22 at 10:00 am revealed: 1, 10oz bottle of cranberry juice with an expiration date of 13dec21. 2, 8oz bottles of a nutritional drink with an expiration date of 17mar2022. There were 2, 2-liter opened and 2/3 empty bottles of unlabeled soda in the center wall cabinet. Observation of the south nutrition room, freezer, and refrigerator on 6/9/22 at 10:15 am revealed: that the freezer had a box of 7 ice cream bars with an expiration date of 1/9/22, a can of crescent roll with an expiration date of 12aug2021, and 2 pints of frozen avocado with an expiration date of 4jul2021. The refrigerator had 9, 8oz bottles of a nutritional drink with expiration dates of 3mar22, and an unlabeled 12oz container of French dip. There was an unlabeled, opened box of crackers in the wall cabinet with an expiration date of 4may22. During an interview with the DON during the observation of the nutrition rooms on 6/9/22 beginning at 10:00 am revealed she did not know who, when, or why there were expired and unlabeled groceries in the nutrition room refrigerators, freezer, and cabinets, nor could she explain the missing documentation in the temperature logs. Record review of the south nutrition refrigerator logs revealed missing documentation: 25 days in April, and 13 days in May. January, February, and March 2022 were missing altogether. Record review of the daily temperature log of the north nutrition refrigerator log was missing documentation: 1 day in Feb, 3 days in Mar, 8 days in April, and 3 days in May. During an interview with HS on 6/9/22 at 3:30 pm revealed: that dietary is responsible for toilet paper, paper towels, and filling soap dispensers as well as ABHR. The process is they are supposed to let me, or anyone in housekeeping, know what they need, usually in person, then I bag it up and give it to them because we're not supposed to go in there. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 8 of 11 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 676174 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy Nursing and Rehabilitation 2202 N Travis Ave Cameron, TX 76520 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview with [NAME] B on 6/9/22 at 4:00 pm revealed: They have not had a cleaning schedule in a while, meaning over a year. She said there had been no cleaning schedule because we just haven't had a chance to do it. She said there's been a lot of new staff. When asked how everything is getting cleaned, she said we just do it (because she has been here 13 years and knows what to do.) When asked how the others know what to do, especially when she's not there, she shook her head from side to side, indicating no, and said it just doesn't get done. She said, it's the supervisor's job to put a new paper for the logs and said nothing when reminded of the current date. She said she is the only staff that cleans the deep fryer because no one else knows how. She said her process was to pour the cooled grease into an underground container that was covered by a grate in the floor of the kitchen, just in front of the soup stove. She said she doesn't know where it goes from there. She said after she dumps the grease, she follows it with a bleach-water solution to keep it clean so it doesn't smell and so no bugs gather. She did not know of any policy regarding the process of disposing of used grease from the deep fryer. During an interview with ADS, DA A, AA, and DA C on 6/9/22 at 4:30 pm revealed ADS said there had not been a cleaning schedule in years because they just hadn't made one. She said, people don't help each other-when I show them how to do something (clean), I show them the right way, but they say that's not how they were trained elsewhere. When asked, as an assistant supervisor, what her role was regarding leadership in the kitchen, she said nothing. When asked if they were aware of the kitchen policies, none of them said anything. They said the process for reporting malfunctioning equipment was to tell HR who in turn would call the company and set up a maintenance visit. AA produced a 2-page cleaning schedule she said was in the filing cabinet in the DM office. (DM was absent from the premises for an interview on 6/9/22) Record review of the 1-page, undated kitchen policy titled cleaning and sanitation of dining and food service areas policy and procedure, states: that the food service staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. Under procedure: 1. the food service manager will record all cleaning and sanitation tasks needed for the department, 2. tasks shall be designated to be the responsibility of specific positions in the department, 3. all staff will be trained on the frequency of cleaning, 4. a cleaning schedule will be posted for all cleaning tasks, and 5. staff will initial the tasks as completed, and staff will be held accountable for cleaning assignments. Record review of the 2-page undated kitchen policy titled, food safety and sanitation policy and procedure, states on page 1: that all local, state and federal standards and regulations are followed to assure a safe and sanitary food service department. Under procedures, number 4. Hair restraints are required . 6. All staff will wash their hands just before they start to work in the kitchen . Under food storage on page 2: 5. Foods are protected from contamination (dust, flies, rodents, and other vermin), 10. Foods with expiration dates are used prior to the use-by date on the package. Record review of the 2-page, undated kitchen policy titled, preventing foodborne illness food handling policy and procedure, states on page 1, under procedure, number 5. Functioning of the refrigeration .will be monitored at designated intervals throughout the day and documented ., 9, all food service equipment and utensils will be sanitized according to current guidelines and manufacturers' recommendations. Observation of the emergency water supply on 6/9/22 at 4:40 pm revealed 141-gallon jugs of water for emergency use. It was stored in an empty room in the 300 hallway that AA led this surveyor to. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 9 of 11 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 676174 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy Nursing and Rehabilitation 2202 N Travis Ave Cameron, TX 76520 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Record review of the census and requirements for emergency water were as such: the census was 53 which would require 371 gallons for the requirement of 1 gallon per resident per day for 7 days, a deficit of 230 gallons. During an interview with HR on 6/10/22 at 8:40 am, he said the process of getting things fixed in the kitchen was what the staff tell him, and he calls the company(s) they use for maintenance of most of the kitchen equipment. If it's something out of his control such as needing an actual replacement of the equipment or an expensive replacement part in general, he lets the corporate dietary head know because he was the one who had to sign off on purchases of that nature. (CDH was unavailable for the survey because he was attending a retreat) He said there was no official log for staff to report equipment failures. Regarding the ice machine, he said it had been acting up as evidenced by an invoice dated 2/16/22. He said the ice machine had stopped making ice again on 6/3/22 and that was when he instructed DM by phone to remove the panel for her to run a cycle and clean, which he said was like a re-set button. He said it took about 15 minutes or so to start making ice again after the cycle and clean button was activated. He adamantly denied the ice in the contaminated ice machine was being rinsed and used for resident consumption over the weekend of 6/3/22 to 6/5/22. He said he personally was purchasing ice from local stores from 6/6/22-to 6/9/22 when a new ice machine was installed. He could not account for the ice used over the weekend. Regarding the grease trap in the kitchen-He said he did not know what the processes are, he was unaware of any policy, and did not know about the grate covering an underground compartment in the kitchen. He said he thought the grease was discarded in a grease trap outside by the smoking area. He said he unlocks it so the grease truck can empty it, and realized he was talking about access to the containment area, as staff did not carry used grease to dispose of outside. He said he was unaware the commercial mixer was broken again because he thought that it was recently fixed when it had not been fixed according to kitchen staff. Regarding the 36-gallon soup stove: He said it had been broken forever he thought since late 2021 and could not recall what the issue was. Record review of 1-page, undated kitchen policy titled, fryer, cleaning policy and procedure: fryers will be cleaned on a regular basis and cared for in such a way to maintain optimum production. The body of the document does not describe the process of how and where the removed oil is disposed of, only the cleaning of the equipment, and not to pour oil down the sink drains. Record review of invoices: #16891, dated 1/31/22 for the soup stove revealed the unit was not a griddle, but a brazing pan used as a griddle. Found unit off and without power .need to call an electrician to trace wire and find power. Invoice # 16950 dated 2/16/22 for the ice machine revealed it was in working order after it had been serviced and parts replaced and/or cleaned. Invoice # 019373, dated 6/1/22 for the freezer compressor revealed: . spoke with the administrator about the ice machine and cleaned it. Invoice/ purchase order # 382589 dated 6/7/22 revealed the purchase and receipt of a new ice machine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 10 of 11 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 676174 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy Nursing and Rehabilitation 2202 N Travis Ave Cameron, TX 76520 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 0838 Level of Harm - Potential for minimal harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on interviews and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies for 1 of 1 facility reviewed for facility assessment. The facility did not have a completed Facility Assessment. This failure could place all residents at risk of a lack of necessary resources. Findings Included: Record review of the facility's records on 06/10/22 revealed they did not have a facility assessment. During an interview on 06/10/22 at 8:51 am the Assistant Administrator said she could not find a facility assessment and did not know what this document would look like. During an interview on 06/10/22 at 9:05 am the Administrator said she was not aware that a facility assessment was required or what the facility assessment should have contained. The Administrator said she would call corporate office to ask if a facility assessment had been completed. She said there was no policy for facility assessment that she was aware of. On 06/10/22 at 10:05 am the Administrator said the facility did not have a facility assessment completed or documented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 11 of 11