Health inspection·September 28, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 09/28/2023 at 10:41 AM the ADON stated she had been working at the facility since May of 2023. She stated call lights should always be in reach for all residents as their needs might not be met. She stated Resident #34 was a high fall risk and could be in danger if she could not reach her call light. In an interview on 09/28/2023 at 10:47 AM the DON stated call lights should be in reach for all residents as the potential risk is their basic needs might not be met. Review of the facility's undated policy and procedure titled Call Light, Use of Policy and Procedure reflected Procedure: When providing care to residents be sure to position the call light conveniently for the resident to use. Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 2 of 18 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 09/28/2023 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that the resident had the right to be free from any physical or chemical restraints imposed for purposed of discipline or convenience and not required to treat the resident's medical symptoms and, when the use of restraints was indicated, to use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints for one of two residents (Residents #43) reviewed for restraints, in that: Residents Affected - Few Resident #43 was physically restrained in a wheelchair with a Velcro seat belt without a plan of care for the device. These deficient practices could place residents who were at risk for falls and/or wandered at risk of unnecessary confinement. Finding Included: Review of Resident #43's Face Sheet dated 09/27/2023 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Osteoporosis (A condition when bone strength weakens and is susceptible to fracture. It usually affects hip, wrist, or spine.), Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), Hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms varies from person to person and generally include unexplained fatigue and headache.) and Atrial Fibrillation (A disease of the heart characterized by irregular and often faster heartbeat.). Review of Resident #43's Quarterly MDS dated [DATE] reflected Resident #43 was assessed to have a BIMS score of two indicating severe cognitive impairment. Resident #43 was assessed to require limited to extensive assist with ADLs. Further review of Resident #43's MDS assessment reflected she was assessed to not have restraints in chair or that her chair prevented rising. Review of Resident #43's Comprehensive Care Plan reflected a focus area initiated on 05/04/2023 and revised on 08/11/2023 I am at risk for falls related to frequent incontinence, dementia, impaired mobility. Intervention included an intervention dated 07/25/2023 Self-releasing seatbelt to my wheelchair. Further review of Resident #43's care plan reflected no plan of care for the use of the seatbelt. Review of Resident #43's Consolidated Physician orders reflected an order dated 08/03/2023 Observe placement and positioning of Soft, Velcro, Self-Releasing Seat Belt when in wheelchair Q shift and PRN. (Reposition device as needed and assess resident's ability to self-release the device Q shift and PRN). Review of Resident #43's TAR dated September 2023 reflected an entry to Observe placement and positioning of Soft, Velcro, Self-Releasing Seat Belt when in wheelchair Q shift and PRN. (Reposition device as needed and assess resident's ability to self-release the device Q shift and PRN). The entry was signed at 7:00 AM and 7:00 PM daily. Observation and interview on 09/26/2023 at 10:12 AM revealed Resident #43 up in wheelchair wheeling (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 3 of 18 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 09/28/2023 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few self in the hall. Resident #43 was observed to have a Velcro type seat belt on her wheelchair. When Resident #43 was asked what the device was and if she could take it off Resident #43 did not answer and smiled and continued to wheel herself down the hall. Observation on 09/27/2023 at 8:00 AM revealed Resident #43 up in wheelchair in hall with seat belt in place. Review of Resident #43's Safety Device Consent form dated 08/03/2023 reflected verbal consent was obtained from her responsible party for a Velcro self-releasing seat belt for poor balance and poor safety awareness. Review of Resident #43's Safety Device Reduction/ Elimination assessment dated [DATE] reflected Resident #43 was a poor candidate for device reduction related to Medical symptoms include frequent attempts to self-transfer without asking for assistance. The resident has very poor Safety awareness related to Dementia. In an interview on 09/28/2023 at 9:29 AM the DON stated Resident #43 could remove her seat belt. She stated the resident did not have a specific care plan for the use of her seat belt and Resident #43's care plan should include a release schedule and specific interventions for the use of the seat belt. Review of the facility's undated policy Restraint Devices, Physical Policy and Procedure reflected Purpose: . To prevent the resident from injuring himself or others. Restraints of any type will not be used as punishment or as a substitute for more effective medical and nursing care or for the convenience of the facility staff . Develop or review resident care plan for type of restraint device, reason for use, alternate methods to be used and method of application. List medical symptoms to be treated and methods to reduce and eliminate the restraint device .add the safety device and/ or skin device to the resident's care plan . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 4 of 18 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 (X3) DATE SURVEY COMPLETED A. Building 09/28/2023 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to transmit resident assessments within the required time frames for 2 of 10 Residents (#27 and #34) reviewed for MDS assessments. Residents Affected - Few A) The facility failed to complete and submit a discharge MDS for Resident #27. B) The facility failed to submit a Quarterly MDS for Resident #34. These failures could place residents at risk of not having their resident specific information submitted for payment and quality measure purposes. Findings included: A. Review of Resident #27's Face Sheet dated 09/28/23, reflected a [AGE] year-old female who was discharged on 05/31/2023. Review of Resident #27's MDS assessment history, reflected no discharge MDS was completed. Review of Resident #27's undated care plan, reflected Resident #27 was care planned for receiving long term care. Review of Resident #27's progress notes, reflected Resident #27 was sent to the hospital on [DATE]. In an interview on 09/28/2023 at 9:50 AM the MDS Coordinator stated a discharge MDS should have been completed for Resident #27 due to her being admitted into the hospital before she passed away. He further stated a discharge MDS should have been completed within 24 hours of a resident being discharged from the facility and Resident #27's discharge MDS was in progress and would be completed. In an interview with the DON on 09/28/2023 at 11:06 am, DON stated Resident #27 should have discharge MDS are completed within 14 days of a resident being discharge home or admitted to the hospital. DON stated that if the discharge MDS is not completed within 14 days then the facility would be out of compliance. B. Review of the undated Face Sheet for Resident #34 reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing-related problems), Chronic Respiratory Failure with Hypoxia (low blood oxygen levels), and personal history of other Malignant Neoplasm (cancer) of Bronchus (central passageway into the lung) and Lung. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 5 of 18 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 09/28/2023 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 0640 Level of Harm - Minimal harm or potential for actual harm Review of the Care Plan for Resident #34 dated 05/01/2023 reflected she was at risk for falls related to cognitive deficit, unsteady balance, history of falls, psychotropic [affect a person's mental status] medications and generalized weakness. Falls 4/3/23, 5/27/23, 6/23/23, 8/10/23, 9/19/23 and 9/26/23. Goal: I will not experience any injuries related to falls. Interventions/Tasks: 5/27/23 Staff will encourage me to call for assistance with all transfers. 09/26/23 Remind me to ask for assist with all ambulation. Residents Affected - Few Review of the quarterly MDS for Resident #34 dated 08/06/2023 reflected she had BIMS score of 2 indicating severe cognitive impairment. Her functional status reflected she required staff assistance for transfer. In an interview on 09/28/2023 at 10:26 AM the MDS Coordinator stated he sent an MDS spreadsheet to the DON at the end of each week and she signed the assessments. He further stated he forgot to submit the MDS assessment for Resident #34 dated 08/06/2023. In an interview on 09/28/2023 at 10:33 AM the DON stated she looked online every week and signed MDS assessments. She stated the MDS for Resident #34 dated 08/06/2023 was not submitted as it should have been. In an interview on 09/28/2023 at 11:00 AM the ADM stated the facility follows the RAI Manual guidelines to submit MDS assessments and did not have a separate policy. Review of the RAI Manual Version 1.17.1 dated October 2019 reflected Discharge Assessments - return not anticipated should be transmitted at the MDS Completion Date plus 14 calendar days. The RAI Manual reflected the Quarterly MDS non-comprehensive assessment should be transmitted no later than the MDS completion date plus 14 calendar days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 6 of 18 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 09/28/2023 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 - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a person-centered care plan to maintain a resident's practicable wellbeing for one of two residents (Resident #43) reviewed for restraints and one of one resident (Resident #41) reviewed for bed rails. A) The facility failed to ensure Resident #43 who was physically restrained in a wheelchair with a Velcro seat belt without a plan of care for the device. B) Resident #41 was observed in bed with full bed rails on both sides of the bed. Resident #41 did not have a plan of care for the full bed rails. This deficient practice could place residents who were at risk for falls and/or wandered at risk of unnecessary confinement and could place residents at risk for entrapment. Finding Included: A) Review of Resident #43's Face Sheet dated 09/27/2023 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Osteoporosis (A condition when bone strength weakens and is susceptible to fracture. It usually affects hip, wrist, or spine.), Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), Hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms varies from person to person and generally include unexplained fatigue and headache.) and Atrial Fibrillation (A disease of the heart characterized by irregular and often faster heartbeat.). Review of Resident #43's Quarterly MDS dated [DATE] reflected Resident #43 was assessed to have a BIMS score of two indicating severe cognitive impairment. Resident #43 was assessed to require limited to extensive assist with ADLs. Further review of Resident #43's MDS assessment reflected she was assessed to not have restraints in chair or that her chair prevented rising. Review of Resident #43's Comprehensive Care Plan reflected a focus area initiated on 05/04/2023 and revised on 08/11/2023 I am at risk for falls related to frequent incontinence, dementia, impaired mobility. Intervention included an intervention dated 07/25/2023 Self-releasing seatbelt to my wheelchair. Further review of Resident #43's care plan reflected no plan of care for the use of the seatbelt. Review of Resident #43's Consolidated Physician orders reflected an order dated 08/03/2023 Observe placement and positioning of Soft, Velcro, Self-Releasing Seat Belt when in wheelchair Q shift and PRN. (Reposition device as needed and assess resident's ability to self-release the device Q shift and PRN). Review of Resident #43's TAR dated September 2023 reflected an entry to Observe placement and positioning of Soft, Velcro, Self-Releasing Seat Belt when in wheelchair Q shift and PRN. (Reposition device as needed and assess resident's ability to self-release the device Q shift and PRN). The entry was signed at 7:00 AM and 7:00 PM daily. Observation and interview on 09/26/2023 at 10:12 AM revealed Resident #43 up in wheelchair wheeling (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 7 of 18 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 09/28/2023 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 - Few self in the hall. Resident #43 was observed to have a Velcro type seat belt on her wheelchair. When Resident #43 was asked what the device was and if she could take it off Resident #43 did not answer and smiled and continued to wheel herself down the hall. Observation on 09/27/2023 at 8:00 AM revealed Resident #43 up in wheelchair in hall with seat belt in place. Review of Resident #43's Safety Device Consent form dated 08/03/2023 reflected verbal consent was obtained from her responsible party for a Velcro self-releasing seat belt for poor balance and poor safety awareness. Review of Resident #43's Safety Device Reduction/ Elimination assessment dated [DATE] reflected Resident #43 was a poor candidate for device reduction related to Medical symptoms include frequent attempts to self-transfer without asking for assistance. The resident has very poor Safety awareness related to Dementia. In an interview on 09/28/2023 at 9:29 AM the DON stated Resident #43 could remove her seat belt. She stated the resident did not have a specific care plan for the use of her seat belt and Resident #43's care plan should include a release schedule and specific interventions for the use of the seat belt. Review of the facility's undated policy Restraint Devices, Physical Policy and Procedure reflected Purpose: . To prevent the resident from injuring himself or others. Restraints of any type will not be used as punishment or as a substitute for more effective medical and nursing care or for the convenience of the facility staff . Develop or review resident care plan for type of restraint device, reason for use, alternate methods to be used and method of application. List medical symptoms to be treated and methods to reduce and eliminate the restraint device .add the safety device and/ or skin device to the resident's care plan . B)Review of Resident #41's Face sheet dated 09/27/2023 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Alzheimer's Disease (A type of brain disorder that causes problems with memory, thinking and behavior. This is a gradually progressive condition.), Vascular Dementia (A condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and memory.), Chronic Kidney Disease, Stage 3 (kidneys are damaged, but they still work well enough that you do not need dialysis or a kidney transplant. Kidney disease often cannot be cured in Stage 3, and damage to your kidneys normally is not reversible.), and Spinal Stenosis (A condition where spinal column narrows and compresses the spinal cord.) Review of Resident #41's Quarterly MDS dated [DATE] Resident #41 was assessed to have a BIMS score of one indicating severe cognitive impairment. Resident #41 was assessed to require extensive to dependent assist with ADLs. Resident #41 was assessed to not have Bed rails. Review of Resident #41's Consolidated Physician Orders reflected an order dated 05/25/2023 Provide fall matt at bedside side rails x 2. Further review reflected an order dated 05/05/2023 for hospice services. Review of Resident #41's Comprehensive Care plan reflected a focus area initiated on 04/24/2023 and revised on 06/18/2023 I am at risk for falls r/t weakness, Alzheimer's, poor impulse control (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 8 of 18 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 09/28/2023 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 - Few 6/18/23- Unwitnessed fall, no injuries. Interventions included 6/18/23- staff to evaluate me for a scoop mattress .Provide Fall [NAME] at my Bedside to minimize risk of injury. Further review of care plan reflected no entries related to siderails. Review of Resident #41's Safety Device Consent form dated 07/31/2023 reflected consent for siderails to maintain body alignment and increase resident sense of safety and security. Observation and interview on 09/26/2023 at 10:15 AM revealed Resident #41 in room in bed. Resident #41 was not interviewable. Resident #41 had full side rails that enclosed both sides of the bed with approximately 6 inches of space and the head and foot of the bed. Resident #41 was further noted to be in a low bed with a bolster mattress with a fall matt noted underneath the bed. Resident #41#s Responsible Party was in the room. Resident #41's RP stated the bedrails were used whenever Resident #41 was in bed. When asked if she had ever tried to climb out of the bed over the siderails he stated yes, she had but she was not able to get out of the bed. Observation on 09/27/2023 at 7:51 AM revealed Resident #41 was in bed with both full bed rails up. In an interview on 09/27/2023 at 2:00 PM AM LVN A stated Resident #41 did have full bed rails and were used whenever she was in bed. When asked why she had them on her bed she stated she was not sure, but they were on the bed that hospice brought in. When asked if she could put the bed rails down on her own, she stated no. In an interview on 09/28/2023 at 9:00 AM CNA D stated Resident #41's bedrails were used when she was in bed, so she did not fall out of bed. In an interview on 09/28/2023 at 9:29 AM the DON stated Resident #41 did have full bedrails and Resident #41 was not able to put them down on her own. The DON stated the use of the bedrails should be care planned. The DON further stated the full bedrails should not be used since they prohibited Resident #41 from getting out of bed on her own making them a restraint. Review of the facility's undated policy Restraint Devices, Physical Policy and Procedure reflected Purpose: . To prevent the resident from injuring himself or others. Restraints of any type will not be used as punishment or as a substitute for more effective medical and nursing care or for the convenience of the facility staff . Develop or review resident care plan for type of restraint device, reason for use, alternate methods to be used and method of application. List medical symptoms to be treated and methods to reduce and eliminate the restraint device .add the safety device and/ or skin device to the resident's care plan . The facility did not provide a policy for the use of bed rails. Review of the facility's undated policy Care Planning Policy and Procedure reflected To provide a comprehensive plan of care addressing resident's needs, strengths, goals, and approaches. Policy: Each resident's care plan will remain current and inform staff of resident's needs, strengths, goals, and approaches . Resident #26 Accidents Resident [NAME] is a smoker. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 9 of 18 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 09/28/2023 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 Resident [NAME] has been assessed for smoking. Level of Harm - Minimal harm or potential for actual harm Resident [NAME] is not care planned for smoking Residents Affected - Few 09/28/23 - 09:50 [NAME] Martinize - MDS Coordinator - stated that the care plan is a projection of care for the resident rather long or short term, list of diagnose and preventions. Care plan also assist with a overview of the care that should be provided to the resident. [NAME] stated that if a resident is smoker then that resident should be care plan for smoking. [NAME] stated if a resident is not care planned for smoking then the resident may not be identified as a smoker, or there could side effects from the medication and smoking. The smoker have instruction in PPC for the residents. 09/28/23 - 11:06am DON Waldene Herring stated that the purpose of the care plan so staff can know what care the resident should be receiving. if a resident is a smoker then they should be care planned. DON stated if a resident is not care planned for smoking that the resident could be a harm to them or others, and harm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 10 of 18 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 09/28/2023 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 received care, consistent with professional standards of care to prevent development or worsening of pressure ulcers for one of two (Resident #22) residents reviewed for pressure ulcers. Residents Affected - Few The facility failed to ensure Resident #22 received his physician ordered pressure ulcer preventative measures routinely. This failure could place residents at risk for worsening pressure ulcers leading to discomfort, pain, and potential infections. Findings included: Review of Resident #22's Face Sheet dated 09/27/2023 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses Hemiplegia and Hemiparesis (Hemiplegia is a symptom that involves one-sided paralysis. Hemiplegia affects either the right or left side of your body.), Cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain. It is caused by disrupted blood supply (ischemia) and restricted oxygen supply (hypoxia).) and Aphasia (A comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to the specific area in the brain.) Review of Resident #22's Annual MDS dated [DATE] reflected Resident #22 was assessed to have a BIMS score of four indicating severe cognitive impairment. Resident #22 was assessed to be dependent on staff for ADL assistance. Resident #22 was assessed to be at risk for developing pressure ulcers, to not currently have pressure ulcers and to have pressure reducing devices for bed. Review of Resident #22's Comprehensive Care Plan reflected a focus area initiated on 04/25/2023 I am at risk for skin breakdown related to impaired mobility, incontinence of bowel and bladder, and CVA with Left Hemiplegia. Listed under interventions was an intervention dated 05/24/2023 Provide Bilateral Heel Protectors. Review of Resident #22's Consolidated Physician orders reflected an order dated 05/24/2023 to float heels when in bed. Further review reflected an order dated 05/24/2023 for bilateral heel protectors. Review of Resident #22's TAR dated September 2023 reflected an entry for Bilateral Heel protectors every shift and an entry to float heels when in bed (suspending the heels in order to prevent pressure points.) Observation and interview on 09/26/2023 at 10:45 AM revealed Resident #22 in room in bed. Resident #22 was not interviewable. Resident #22 was noted to not have heels floated or heel protectors on, his feet were pressed against the foot board. Observation on 09/27/2023 at 8:15 AM revealed Resident #22 in bed. His heels were not floated, and he did not have heel protectors on. Observation on 09/27/2023 at 9:45 AM revealed Resident #22 being Hoyer lift transferred to bed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 11 of 18 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 09/28/2023 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 0686 after his shower. Skin check revealed multiple healed scars to his left ankle and left side of foot. Level of Harm - Minimal harm or potential for actual harm Observation on 09/27/2023 at 10:02 AM revealed Resident #22 in bed dressed his heel protectors were not on. Residents Affected - Few Observation and interview on 09/28/2023 at 9:09 AM revealed Resident #22 in bed with floating boots on. In an interview with LVN A she stated Resident #22 was supposed to have his floating boats on at all times when in bed. LVN A stated she did not know why they were not on yesterday. In an interview on 09/28/2023 at 9:29 AM the DON stated she expected residents who had pressure ulcer prevention interventions in place for those interventions to be in place. The DON further stated Resident #22 did have a history of skin breakdown and his heels should be floated when he is in the bed. Review of the facility's undated policy Skin care Policy and Procedure reflected Purpose: To maintain and prevent further skin breakdown. The facility will accomplish these goals through prevention, assessment, and treatment . Use pressure reducing or relieving devices as necessary . Position with appropriate surfaces to protect bony prominences . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 12 of 18 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 09/28/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for 1 of 5 Residents (#34) reviewed for accidents hazards, in that:. Resident #34 was observed in her bed with her bed in a high position and her fall mat not positioned in place beside her bed. This failure could affect residents at risks for accidents and injury. Findings included: Review of the undated Face Sheet for Resident #34 reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing-related problems), Chronic Respiratory Failure with Hypoxia (low blood oxygen levels), and personal history of other Malignant Neoplasm (cancer) of Bronchus (central passageway into the lung) and Lung. Review of the Care Plan for Resident #34 dated 05/01/2023 reflected she was at risk for falls related to cognitive deficit, unsteady balance, history of falls, psychotropic [affect a person's mental status] medications and generalized weakness. Falls 4/3/23, 5/27/23, 6/23/23, 8/10/23, 9/19/23 and 9/26/23. Goal: I will not experience any injuries related to falls. Interventions/Tasks: 5/27/23 Staff will encourage me to call for assistance with all transfers. 09/26/23, I use a low bed. Remind me to ask for assist with all ambulation. 05/24/2023 Fall mat to side of bed. Review of the quarterly MDS for Resident #34 dated 08/06/2023 reflected she had BIMS score of 2 indicating severe cognitive impairment. Her functional status reflected she required staff assistance for transfer. Observation on 09/28/2023 at 9:00 AM revealed Resident #34's bed was not in low position and her fall mat was not beside her bed. In an interview on 09/28/2023 at 9:02 AM CNA A stated she had been working at the facility since March 2023. She stated she did not put Resident #34's fall mat beside her bed and did not lower the bed to low position after she assisted her with breakfast. She stated it could increase her risk of having a fall and she was aware that it should have been done but did not do it. In an interview on 09/28/2023 at 9:10 AM LVN B observed the fall mat not beside Resident #34's and stated it should have been her bed due to her high fall risk. She stated her bed should have been in a low position because she was a high fall risk. In an interview on 09/28/2023 at 10:41 AM the ADON said Resident #34's bed should have been put in a low position and her fall mat should have been placed back by her bed so she wouldn't hit the floor if she fell out of bed. She did not state how residents were monitored. In an interview on 09/28/2023 at 10:47 AM the DON stated fall mats should be in place to prevent or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 13 of 18 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 09/28/2023 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 0689 minimize injury and Resident #34 was a fall risk. Level of Harm - Minimal harm or potential for actual harm Review of the facility's undated policy and procedure titled Fall Prevention reflected Programs: Fall Prevention. Equipment: low bed with fall mat. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 14 of 18 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 09/28/2023 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 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 respiratory care was provided consistent with professional standards of practice for 2 of 4 Residents (Resident #55 and #46) reviewed for respiratory care. Residents Affected - Few A) The facility failed to ensure Resident 55's oxygen tubing was changed weekly. B) The facility failed to ensure Resident #46's oxygen tubing was covered when not in use. This failure could place all residents who use respiratory equipment at risk for respiratory infections. Findings included: A. Review of Resident #55's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Chronic Respiratory Failure with Hypoxia (low blood oxygen levels), Panlobular Emphysema (damage to the air sacs within the lungs), and Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing-related problems). Review of Resident #55's Care Plan dated 04/28/2023 reflected I have Chronic Obstructive Pulmonary Disease. Goal: My respiratory problem with be at a minimum level. Interventions/Task: I need oxygen when I have a respiratory crisis. Review of Resident #55's Annual MDS dated [DATE] reflected she had a BIMS score of 15 indicating intact cognitive status. Other health conditions reflected she had shortness of breath or trouble breathing with exertion and when lying flat. Review of Resident #55's Physician orders dated 04/16/2023 reflected Change oxygen lines, nebulizer tubing and masks Q week per facility policy. Observation on 09/26/2023 at 10:52 AM in Resident #55's room revealed her oxygen tubing was dated 09/03/2023. Observation on 09/27/2023 at 8:45 AM revealed Resident #55's oxygen tubing was still dated 09/03/2023. In an interview on 9/28/2023 at 9:25 AM LVN B stated the oxygen tubing for Resident #55 was way overdue to be changed and it was an infection control issue for the resident. She stated the nurses on Sundays were responsible for changing the oxygen tubing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 15 of 18 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 09/28/2023 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 09/28/2023 at 10:41 AM the ADON stated the facility policy was for all oxygen tubing to be changed weekly every Sunday night to reduce the risk of infection for a resident. In an interview on 09/28/2023 at 10:47 AM the DON stated oxygen tubing should be changed weekly, for prevention of infection and to minimize the risk to the resident. She did not state how the facility monitored orders to ensure they were being followed. B. Review of Resident #46's undated Face Sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing-related problems), and Pleural Effusion (a buildup of fluid between the tissues that line the lungs and the chest). Review of Resident #46's Care Plan dated 04/28/2023 reflected Focus: 05/03/2023 I have poor endurance due to shortness of breath r/t COPD. Administer my oxygen as ordered. Review of Resident #46's Annual MDS dated [DATE] reflected he had a BIMS score of 2 indicating severe cognitive status. Other health conditions reflected he had shortness of breath when lying flat. Review of Resident #46's Physician orders dated 08/05/2023 reflected oxygen run at 2-3 LPM via nasal cannula to keep O2 SATS > 90% with SOB, SOB when lying flat. Observation on 09/26/2023 at 1:03 PM in Resident #46's room revealed his oxygen tubing was not bagged and was on top of his bedspread. In an interview on 09/28/2023 at 9:10 AM LVN B stated Resident #46's oxygen tubing should be bagged when not in use as leaving it on the bedspread was an infection control issue. In an interview on 9/28/2023 at 10:35 AM the facility ICP stated it was a big problem if oxygen tubing is left on a bed and it should have been thrown away because it was contaminated. She stated the tubing could pick up bacteria and cause an infection in the resident's lungs. In an interview on 09/28/2023 at 10:41 AM the ADON stated the facility policy stated tubing should not be left on top of a bed because of the risk of infection, respiratory, if left on the bed it should be replaced. In an interview on 09/28/2023 at 10:47 AM the DON stated oxygen tubing should not be left on top of a bed when not in use and it should be bagged to prevent contamination and respiratory infection. Review of the facility undated policy and procedure titled Oxygen Concentrator Cleaning Policy and Procedure reflected Purpose: To keep oxygen concentrator and equipment clean. Procedure: Store oxygen tubing, cannula, and mask in plastic bag when not in use. Oxygen tubing, cannula, and mask to be changed out weekly and as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 16 of 18 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 09/28/2023 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to assess the resident for risk of entrapment from bed rails prior to installation for one of one resident (Resident #41) reviewed for bed rails Resident #41 was observed in bed with full bed rails on both sides of the bed. Resident #41 did not have a plan of care for the full bed rails or an assessment for entrapment risk in the resident's record. This deficient practice could place residents at risk for entrapment with injury. Findings Included: Review of Resident #41's Face sheet dated 09/27/2023 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Alzheimer's Disease (A type of brain disorder that causes problems with memory, thinking and behavior. This is a gradually progressive condition.), Vascular Dementia (A condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and memory.), Chronic Kidney Disease, Stage 3 (kidneys are damaged, but they still work well enough that you do not need dialysis or a kidney transplant. Kidney disease often cannot be cured in Stage 3, and damage to your kidneys normally is not reversible.), and Spinal Stenosis (A condition where spinal column narrows and compresses the spinal cord.) Review of Resident #41's Quarterly MDS dated [DATE] Resident #41 was assessed to have a BIMS score of one indicating severe cognitive impairment. Resident #41 was assessed to require extensive to dependent assist with ADLs. Resident #41 was assessed to not have Bed rails. Review of Resident #41's Consolidated Physician Orders reflected an order dated 05/25/2023 Provide fall matt at bedside side rails x 2. Further review reflected an order dated 05/05/2023 for hospice services. Review of Resident #41's Comprehensive Care plan reflected a focus area initiated on 04/24/2023 and revised on 06/18/2023 I am at risk for falls r/t weakness, Alzheimer's, poor impulse control 6/18/23Unwitnessed fall, no injuries. Interventions included 6/18/23- staff to evaluate me for a scoop mattress .Provide Fall [NAME] at my Bedside to minimize risk of injury. Further review of care plan reflected no entries related to siderails. Review of Resident #41's Safety Device Consent form dated 07/31/2023 reflected consent for siderails to maintain body alignment and increase resident sense of safety and security. Review of Resident #41's EMR reflected no assessment for entrapment risk. Observation and interview on 09/26/2023 at 10:15 AM revealed Resident #41 in room in bed. Resident #41 was not interviewable. Resident #41 had full side rails that enclosed both sides of the bed with approximately 6 inches of space and the head and foot of the bed. Resident #41 was further noted to be in a low bed with a bolster mattress with a fall matt noted underneath the bed. Resident #41#s (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 17 of 18 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 09/28/2023 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 0700 Level of Harm - Minimal harm or potential for actual harm Responsible Party was in the room. Resident #41's RP stated the bedrails were used whenever Resident #41 was in bed. When asked if she had ever tried to climb out of the bed over the siderails he stated yes, she had but she was not able to get out of the bed. Observation on 09/27/2023 at 7:51 AM revealed Resident #41 was in bed with both full bed rails up. Residents Affected - Few In an interview on 09/27/2023 at 2:00 PM AM LVN A stated Resident #41 did have full bed rails and were used whenever she was in bed. When asked why she had them on her bed she stated she was not sure, but they were on the bed that hospice brought in. When asked if she could put the bed rails down on her own, she stated no. In an interview on 09/28/2023 at 9:00 AM CNA D stated Resident #41's bedrails were used when she was in bed, so she did not fall out of bed. In an interview on 09/28/2023 at 9:29 AM the DON stated Resident #41 did have full bedrails and Resident #41 was not able to put them down on her own. The DON stated the use of the bedrails should be care planned. The DON further stated the full bedrails should not be used since they prohibited Resident #41 from getting out of bed on her own making them a restraint. Review of the facility's undated policy Restraint Devices, Physical Policy and Procedure reflected Purpose: . To prevent the resident from injuring himself or others. Restraints of any type will not be used as punishment or as a substitute for more effective medical and nursing care or for the convenience of the facility staff . Develop or review resident care plan for type of restraint device, reason for use, alternate methods to be used and method of application. List medical symptoms to be treated and methods to reduce and eliminate the restraint device .add the safety device and/ or skin device to the resident's care plan . The facility did not provide a policy for the use of bed rails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 18 of 18