Health inspection·November 14, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few after his toe healed. He stated by not updating the care plan it could have a negative effect on the resident cares and affect his wound care. In an interview on 11/14/2024 at 12:46 PM the DON stated she expected staff to update residents plans of care with any changes to their care. The DON stated the staffs' failure to do so could result in residents not receiving proper care. Review of the facility's policy Care planning policy and procedure (not dated) reflected .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 reviewed with the resident, responsible party and interdisciplinary team quarterly and as needed FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 2 of 19 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 11/14/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 review, the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for two of eight residents (Resident # 34 and Resident #75) reviewed quality of life. Residents Affected - Few 1. The facility failed to ensure Resident #34 nails were cleaned and did not have any rough edges on 11/12/2024. 2. The facility failed to ensure Resident #75 facial hair was removed on 11/12/2024. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: 1. Record review of Resident # 34's Face Sheet dated, 11/13/2024, reflected a [AGE] year-old male admitted on [DATE] with diagnoses of type 2 diabetes mellitus with diabetic polyneuropathy (occurs when high blood sugar levels over time damage nerves), chronic pain ( a long term pain condition that lasts longer than the normal recovery period for an injury or illness ), and peripheral vascular disease ( a condition that occurs when the blood vessels outside of the heart and brain narrow or become blocked, reducing blood flow to the body). Record review of Resident #34's Quarterly MDS Assessment, dated 10/08/2024, reflected the resident had a BIMS score of 8 indicating his cognition was moderately impaired. Resident #34 required partial/moderate assistance ( helper does less than half the effort) with personal hygiene, lower and upper body dressing, showers, and transfers. Record review of Resident #34's Comprehensive Care Plan, with a completed date on 10/25/2024 reflected Resident #34 required staff assistance for all ADLs. Intervention: Assist Resident #34 with hygiene and grooming tasks. Resident #34 had diagnosis of type 2 diabetes. Record review of Resident #34's nurses notes from 10/01/2024 to 11/13/2024 Resident #34 did not refuse nail care. Observation on 11/12/2024 at 9:37 AM, Resident #34 was lying in bed. Resident #34 had blackish / brownish substance underneath his all his nails on his right hand. He had rough edges around his nails on his right hand. In an interview on 11/12/2024 at 9:45 AM, Resident #34 stated he bites his nails when they are long and he was unable to keep them from being rough. Resident #34 stated he asked staff few days ago to cut his nails and clean them. He did not recall the staff name. He stated when his fingernails needed to be cut he would bite them. Resident #34 stated he had few nails to bite for all of his nails to be shorter. He stated when he bites his fingernails they never were straight. Observation on 11/13/2024 at 8:10 AM, Resident #34 was lying in bed. Resident #34 had blackish / (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 3 of 19 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 11/14/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few brownish substance underneath his all his fingernails on his right hand. He had rough edges around his fingernails on his right hand. In an interview on 11/13/2024 at 8:13 AM, Resident #34 stated he requested his fingernails to be cut and cleaned on Saturday (11/09/2024 and Sunday (11/10/2024) and the staff told him someone would come to his room and do nail care sometime that day. He stated he did not recall the staff name. He stated when he was unable to get someone to cut his nails he would bite them off and that was the only way he could get his nails trimmed. Resident #34 stated his nails would be sharp when he was not able to bite them straight. He stated he would get hang nails sometimes and was afraid his nails would become infected. Resident #34 stated he was a diabetic and his nails needed to be trimmed with nail clippers instead of him biting his nails. Resident #34 stated he sometimes would refuse a shower but never refused having his nails trimmed or cleaned. 2. Record review of Resident #75's Face Sheet, dated 11/13/2024, reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of adult failure to thrive ( a syndrome that describes a decline in physical and psychological health in older adults), age-related osteoporosis without current pathological fracture ( when bones become less dense and more likely to break), and weakness ( lack of strength). Record review of Resident #75's Quarterly MDS Assessment, dated 08/27/2024, reflected Resident #75 had a BIMS score of 15 indicating her cognition was intact. Resident #75 required assistance with partial/moderate assistance ( helper does less than half the effort) with personal hygiene, upper body dressing, and toileting hygiene. She required substantial/maximal assistance with showers and lower body dressing. Record review of Resident #75's Comprehensive Care Plan completed on 09/17/2024 reflected Resident #75 required staff assistance for all ADLs. Intervention: assist Resident #75 with hygiene and grooming tasks. Record review of Resident #75's nurses notes from 09/28/2024 to 11/14/2024 reflected Resident #75 did not refuse for facial hair to be removed from face. Observation on 11/12/2024 at 1:31 PM, Resident #75 was sitting in her wheelchair near her bed. She had approximately 1 inch of hair on her chin, on the left and right side of mouth and on her upper lip. In an interview on 11/12/2024 at 1:33 PM, Resident #75 stated she was embarrassed to have hair on her face. She stated she asked the staff yesterday to remove the hair on her face. Resident #75 stated the staff stated they would sometime that afternoon. Resident #75 stated no one came back to her room and removed the hair from her face. She stated she asked someone today to remove the hair from their face and the staff told her they were busy and would do it sometime this weekend. Resident #75 did not recall the staff name or their position. She stated she was so embarrassed to be around people. Resident #75 stated she had always had a lot of pride in her appearance and would never want anyone to see her with hair on her face. In an interview on 11/14/2024 at 8:15 AM, RN A stated the CNAs (Certified Nursing Assistant) was responsible for cleaning, trimming, and filing all residents' nails except for the residents with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 4 of 19 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 11/14/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few diagnosis of diabetes. She stated the nurses was responsible for all residents' nails with diagnosis of diabetes. RN A stated residents nails were usually cleaned on their shower days and as needed. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill such as vomiting, diarrhea and dehydration. RN A stated a resident may cause a skin tear on their skin or another resident's skin if the nail was not filed. She stated she had been in-serviced on cleaning, filing and trimming residents' nails but she did not recall the date. She stated the nurses checked the residents with diabetes nails at least 1-2 times per week. She stated the CNAs would report to the nurses if they observed dirty or long nails of any resident with diagnosis of diabetes. RN A stated Resident #34 refused showers and sometimes medications, however, she was not aware of him refusing nail care. She stated if a female resident had facial hair on their face there was a possibility the resident may isolate themselves in their room. RN A stated she was not aware of Resident #75 refusing facial hair to be removed. In an interview on 11/14/2024 at 8:33 AM, CNA B stated the nurses completed all diabetic fingernails, and the CNAs were responsible for all other residents' nails. She stated the CNAs were responsible to complete nail care such as trimming, filing, and cleaning the nails during showers. CNA B stated if a resident's nails needed to be cleaned, trimmed, or filed and it was not their shower day, the staff were expected to do any type of nail care as needed. CNA B stated if a resident had blackish substance underneath their nails, it was probably some type of bacteria. CNA B stated if a resident swallowed bacteria it was a potential the resident may become ill such as vomiting. CNA B stated if a resident had rough edges around their fingernails, it was a possibility the resident may scratch themselves or scratch their eyes and develop an infection. CNA B stated if a female resident had facial hair on their chin or upper lip, a resident may not want to leave their room. She stated a female resident may become embarrassed over their appearance. CNA B stated she was not aware of Resident #75 refusing for staff to remove facial hair. She also stated the staff would usually remove female's facial hair in shower and/or as needed. CNA B stated Resident #34 had refused showers in the past. She stated she was not aware of Resident #34 refusing nail care. She stated he was a diabetic and the nurses would complete nail care on Resident #34. She stated if all CNAs were required to report to the nurse if they noticed any changes including long and dirty nails to the nurse of the residents with diagnosis of diabetes. In an interview on 11/14/2024 at 8:50 AM, CNA C stated the CNAs was responsible for cleaning, trimming, and filing all residents' nails except for the residents with diagnosis of diabetes. She stated the nurses was responsible for all residents' nails with diagnosis of diabetes. CNA C stated residents' nails were usually cleaned , filed, and trimmed on their shower days. She stated if a resident had a hang nail or their nails were dirty, nail care was expected to be completed as needed. CNA B stated if a resident had nails that were rough around the edges, there was a possibility a resident may scratch themselves and develop a skin tear. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill with stomach issues such as diarrhea. CNA B stated if she saw a resident with a diagnosis of diabetes needed their nails cut or cleaned, she would report it to the nurse. CNA B stated she had been in-serviced on cleaning, filing, trimming residents' nails, and grooming of female residents. She stated she did not remember the date of the in-service. CNA B stated she was not aware of Resident # 34 refusing nail care. She stated sometimes Resident #34 would refuse clothes to be changed. CNA B stated if a female resident had facial hair the female resident may be humiliated if around people. She stated there was a potential for a female resident not wanting to socialize (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 5 of 19 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 11/14/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with others outside of her room. CNA B stated she was not aware of Resident #75 refusing any care including removing facial hair. In an interview on 10/24/2024 at 10:45 AM, Director of Nurses stated if a resident ingested blackish substance on their fingers or underneath their fingernails, there was a possibility the substance may be some type of bacteria. She stated there was a possibility a resident may develop vomiting or diarrhea. She stated all residents was expected to receive nail care during showers and as needed. Director of Nurses stated the CNAs completed nail care on all residents except for the residents with diagnosis of diabetes. She stated all residents with diagnosis of diabetes, the nurse was responsible for their nail care. The Director of Nurses stated she did expect the CNAs to report any changes in all residents' nails to the nurse supervisor. She stated if a resident had rough nails, there was a potential a resident may scratch themselves or someone else and cause a skin tear. The Director of Nurses stated if a female resident had facial hair the resident may become humiliated when around other people. She stated a resident may want to stay in their room to prevent others from seeing her with facial hair. She stated she was not aware of Resident #75 refusing hair to be removed from her face. She stated it was the nurse supervisor responsibility to monitor ADL care. The Director of Nurse stated Resident #34 did refuse showers; however, she was not aware of him refusing nail care. She stated if a resident with a diagnosis of diabetes refused nail care, the nurse was responsible to document the nail care refusal in the nurses' notes. The facility Policy on Nail Care, dated 11/11/2021, reflected the following: Policy: 1. To prevent infection. 2. To prevent irritation. 3. To prevent break in skin integrity 4. To promote peripheral (an infection that occurs in the outer tissues of the body) circulation. 5. To promote cleanliness 6. To relieve pain. Procedure: 1. Care of fingernails and toenails is part of the bath. 2. Be certain nails are clean. 3. If nails are difficult to cut, inform the charge nurse. 4. Nails are to be clipped and filed smoothly. 5. Cut straight across the nails. The podiatrist or licensed nurse clip nails for all diabetic residents and residents with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 6 of 19 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 11/14/2024 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 0677 peripheral vascular disease. Level of Harm - Minimal harm or potential for actual harm 6. Residents who refuse nail care should be reported to the nurse. 7. Apply lotion to skin as needed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 7 of 19 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 11/14/2024 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 each resident received adequate supervision and assistance devices to prevent accidents for one (Resident # 61) of four residents reviewed for accidents and hazards. The facility failed to ensure Resident #61 intervention of a fall mat was placed on the side of the bed on 11/13/2024. This failure could result in residents experiencing accidents, injuries, unrelieved pain, and diminished quality of life. Findings included: Record review of Resident #61's face sheet, dated 11/14/2024, reflected an [AGE] year-old female was admitted to the facility on [DATE] with the following diagnoses of syncope and collapse ( sudden loss of consciousness), unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (dementia [a general term for a decline in mental abilities that affects memory, and reasoning, and can interfere with daily life] where the specific type of dementia cannot be clearly identified and the person does not exhibit any behavioral disturbances), and anxiety (a feeling of fear, dread, and uneasiness). Record review of Resident #61's Quarterly MDS, dated [DATE], reflected Resident # 61 had a BIMS score of 3 indicating her cognition was severely impaired. Resident #61 required supervision with transfers. She required partial/moderate assistance (helper did less than half the effort). Resident #61 Record review of Resident #61's Comprehensive Care Plan of a start date, 09/17/2024 and a completion date of 10/01/2024 reflected Resident #61 was a risk for falls related to impaired mobility, cognitive deficit and functional incontinence, and history of falls. Resident #61 had a fall on 1/11/2024, 3/31/2024, and 4/08/2024. Interventions: low bed with fall mat. Staff to encourage assistance with transfers and toileting. Resident #61 required staff assistance for all ADLs related to cognitive deficit (affects a person's mental processes, including learning, thinking, remembering, and decision-making). Interventions: Resident #61 required assistance with transfers, assistance with ambulation, and bed mobility. Observation and interview on 11/13/2024 at 8:26 AM Resident #61 were lying in bed with eyes opened. A fall mat was located against the chest of drawers on the wall in front of her bed. Resident #61 bed was in low position. Resident #61 was not interview able. In an interview on 11/14/2024 at 8:15 AM, RN A stated the CNA's (certified nurses assistant) were responsible to ensure fall mats was placed beside Resident #61's bed after assisting Resident #61 from wheelchair to bed. She stated Resident #61 did require assistance with transfers most of the time. RN A stated Resident #61 was a fall risk and had a history of falls. RN A stated Resident #61 required a fall mat beside her bed. RN A stated if Resident #61 fell onto the floor without the fall mat beside her bed, there was a possibility Resident #61 may sustain a broken hip, head laceration, broken arm, etc. She stated it was on the [NAME] for Resident #61 to have a fall mat beside her bed. RN A stated it was the CNAs responsibility to place fall mat beside bed and the nurse supervisor's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 8 of 19 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 11/14/2024 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 responsibility to ensure all fall protocols including fall mat was in place. Level of Harm - Minimal harm or potential for actual harm In an interview on 11/14/2024 at 8:33 AM, CNA B Resident #61 was a fall risk. She stated Resident #61 had a history of falling. CNA B stated she had given care to Resident #61 and it was on Resident #61's [NAME] ( a medical record the CNAs refers to and the information is gathered from the comprehensive care plan) to have a fall mat beside Resident #61's bed. CNA B stated Resident #1 would attempt to get out of bed without any assistance. She stated Resident #1 required a fall mat beside her bed as a precaution for falls. CNA B stated Resident #61 had a potential to fall out of bed. She stated if Resident #61 fell out of bed and there was not a fall mat beside his bed, she could break a bone, hit her head on something and cause her head to bleed. CNA B stated there was a possibility Resident #61 injury would be serious and require to be assessed at a hospital. She stated she had received a fall protocol in-service within the past 7 or 8 months. She did not recall the date of the in-service. Residents Affected - Few In an interview on 11/14/2024 at 8:50 AM, CNA C stated Resident # 61 was a fall risk and she had given care to Resident #61. She stated Resident #1 was required to have a fall mat beside her bed whenever Resident #61 was lying in bed. CNA C stated if Resident #61 had fallen off the bed and there were not any floor mats beside his bed, there was a possibility Resident #61 may break a hip, leg, arm or have a head injury. She stated the CNAs reviews the [NAME] in the electronic medical records to confirm what type of care a resident needed. CNA C stated on Resident #61's [NAME] reflected Resident #61 required fall mat beside her bed. CNA C stated when Resident #61 was assisted to bed the fall mat was to be placed beside her bed. She stated she had been in-serviced on falls and fall protocol; however, she did not recall the date. In an interview on 10/24/2024 at 10:45 AM, Director of Nurses stated Resident #61 was required to have a fall mat beside her bed when she was lying in bed. The Director of Nurses stated having fall mat beside Resident #61 bed was on the care plan the CNAs [NAME] record ( a record in computer system to alert CNAs on what type of care each resident needed). The Director of Nurses stated if the fall mat was not beside Resident #61's bed there was a potential if she fell from bed onto the floor, she may sustain injury such as broken leg or a broken arm. The Director of Nurses stated it was the nurse supervisor to ensure all fall devices was in place for all residents assessed to be a fall risk. Facility Policy and Procedure on Fall Protocol, dated 06/20/2204, reflected the following: Purpose: To identify residents at risk for falls, initiate preventative approaches, and provide appropriate strategies and interventions. Policy: Each resident will be assessed on admission, re-admission, quarterly, annual, any significant change in condition, and as needed for potential risk for falls in order to initiate preventative approaches, Discussion regarding the acceptable level of risk must be based on individual assessment with input from the resident and/or interdisciplinary team. Procedure: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 9 of 19 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 11/14/2024 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 1. Care Plan will be updated. Level of Harm - Minimal harm or potential for actual harm Interventions: 2. 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 10 of 19 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 11/14/2024 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for one resident (Resident #50) of 23 residents reviewed for nutrition. Residents Affected - Some The facility failed to ensure Resident #50 maintained acceptable parameters of nutritional status as demonstrated by Resident #50 experiencing a 10.98% weight loss in less than 60 days. These failures could place residents at risk for decreased nutritional status, decline in health, serious illness, or hospitalization. Findings included: Review of Resident #50 face sheet dated 11/14/2024 revealed Resident #50 was a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses on Type 2 Diabetes Mellitus (a long term condition in which the body has trouble controlling blood sugar and using it for energy), Ulcerative colitis (a chronic, inflammatory bowel disease that causes inflammation in the digestive tract), bilateral below the knee amputation, End Stage Renal Disease requiring hemodialysis, congestive heart failure, high blood pressure, anxiety and depression. Review of Resident #50's quarterly MDS assessment dated [DATE] revealed Resident #50 to have a BIMS score of 14 to indicate intact cognition. Resident #50 was noted to require assistance with eating. Resident #50 was not noted to have a swallowing disorder and had no recent weight loss. Resident #50 required a mechanically altered diet and therapeutic diet. Review of Resident #50's Care Plan dated 04/11/2023 revealed Resident #50 required help with my tray set up and verbal cues to help prompt Resident #50. Resident #50 was noted to be at risk for weight loss on 04/11/2023 due to excess fluids being pulled off me at dialysis 3x/week. Interventions included have the dietitian re-evaluate my nutritional status as needed, need my meal served as ordered by my physician, provide me with an attractive setting with socialization opportunity for my meals and weigh me as appropriate. On 10/10/2024, Resident #50 was noted I have altered diet needs I am on a full liquid diet. Interventions included dietitian to evaluate my current nutritional status, I need my diet served to me as ordered, I need my physician and family notified for significant changes and maintain my current listing of food likes and dislikes. Review of Resident #50 Weight records dated 11/13/2024 revealed: 11/07/2024 - 178.4 lbs 10/29/2024 - 187.8 lbs 09/12/2024 - 196.2 lbs 08/15/2024 - 200.4 lbs 05/23/2024 - 194.0 lbs 30 days change (10/29/2024 to 11/07/2024): 9.07% decrease - to indicate severe weight loss (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 11 of 19 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 11/14/2024 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 0692 90 days change 9/12/2024 to 11/07/2024): 10.98% decrease - to indicate severe weight loss Level of Harm - Minimal harm or potential for actual harm 6 month change (5/23/2024 to 11/07/2024): 8.04% decrease - to indicate significant weight loss Residents Affected - Some In an observation and interview on 11/12/2024 at 10:24 AM, Resident #50 stated she was in pain related to a fractured leg and back that she sustained in October 2024 after the transportation company (not related to facility) dropped her out of the transport van. She complained of decreased appetite and did not feel like eating. Resident #50 stated the nurse brought her pain medication as scheduled which helped with the pain. Resident #50's breakfast tray was observed on her bed side table with none of the food eaten. In an interview on 11/14/2024 at 9:30 AM, LVN G stated Resident #50 has had decreased intake and poor appetite since she broke her leg and back after the transport van dropped her. She said they encourage her to eat and offer her an alternative if she did not eat the main entrée. She said she was not sure if Resident #50 has lost weight in the last few months. She stated the restorative aides were in charge of resident weights and alert the DON to changes. When asked if she was aware Resident #50 lost 22 pounds since August 2024, she said no. She said she was not aware of any new nutrition interventions put into place for Resident #50. She stated they could offer alternative foods or a nutrition supplement shake. She stated other nurses have not brought the weight loss to her attention. She stated she was not sure if the dietitian had evaluated Resident #50. She stated Resident #50 was non-compliant with her diet and would eat food if her family brought her food from outside sources. In an interview on 11/14/2024 at 9:45 AM, the DM stated she was not aware of any diet interventions for weight loss for Resident #50. She stated Resident #50's diet was liberalized by her physician because of decreased intake. She stated she was not aware of supplements of fortified foods being ordered. She stated in the past Resident #50 refused health shakes or other supplements. She stated she was not aware of anyone offering Resident #50 a health shake for the current weight loss. She stated they did not have renal friendly health shakes at this time. In an interview on 11/14/2024 at 10:30 AM, CNA H stated Resident #50 had decreased appetite over the last month or so. She stated Resident #50's blood sugar has been running low due to decreased oral intake. She stated Resident #50's doctor decreased her insulin and liberalized her diet from renal to no concentrated sweets regular diet. She stated she did not know if Resident #50 started eating more when her diet was liberalized. She stated Resident #50 was offered a health shake in the past and refused. She said it had been months since Resident #50 tried a health shake. She stated she was not aware of Resident #50's weight loss and that the nurses would address weight loss. She stated she encouraged Resident #50 to eat her food and offered her a sprite when she didn't want anything else to eat or drink. She was not aware of any other interventions that have been put into place to prevent further weight loss in Resident #50. In an interview on 11/14/2024 at 10:40 AM, the DON stated she was not aware of 20+ pound weight loss in the last two months for Resident #50. She stated they discuss weight loss daily at the morning meeting and Resident #50 had not triggered. She stated the dietitian should have evaluated Resident #50 when the weight loss was discovered. She stated the dietitian has not evaluated Resident #50 for weight loss or made any new recommendations. She stated normally if a resident triggers for weight loss, the dietitian will evaluate them and make recommendations. She stated they then speak with the resident's physician for orders and then start a new intervention like health shakes, fortified foods and/or double portions. She stated the dietitian comes to the facility monthly to review all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 12 of 19 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 11/14/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some residents and then weekly the dietitian looks at the weight variance report. She stated if a resident triggers on the weekly report, the dietitian will make recommendations remotely and forward to the facility staff. She stated she did not know why the dietitian did not note the severe weight loss in Resident #50. She stated the DM will also address weight loss by looking a food-preferences, likes and dislikes, of residents to increase intakes. She stated the weight loss should be addressed as soon as its noted by re-checking the weight, asking for a dietitian assessment and notifying the physician for order changes. She stated these had not been done for Resident #50 and she was not sure why the dietitian had not evaluated Resident #50. In an interview on 11/14/2024 at 11:30 AM, the RD stated she had not evaluated Resident #50 for weight loss. She was not aware of Resident #50's recent weight loss of 22 pounds since August 2024. She stated normally she would pick up on weight loss from the weight variance report she reviews weekly. She stated she was at the facility on 11/07/2024 and did not note the weight loss from 10/29/2024 and/or 11/07/2024. She stated the restorative aide that did the weights must not have put the new weight in the system when she was at the facility. She stated the restorative aide does all of the monthly weights so the weights were consistent. She stated she reviewed the weights for everyone monthly and then she reviewed them weekly remotely. She stated she will make recommendations and notify the nursing staff. She stated the physician will order interventions based on her recommendations. She stated for Resident #50 interventions for weight loss might include a renal friendly health shake, fortified foods with meals, snacks, ice cream with lunch and dinner, med pass supplementation and/or double portions. She knew Resident #50 had decreased appetite due to pain from Resident #50's fractured leg and back. She stated she thought Resident #50's nutrition needs were increased due to the healing fractures and the decreased intake might slow her healing time. Review of Resident #50's Dietary Managers Nutritional Review, dated 09/18/2024 revealed Resident #50 had unplanned weight loss in the past 3-6 months of greater than 10% to indicated Resident #50 was at high risk. High risk indicated Resident #50 should be treated for weight loss. Resident #50's diet order was noted to be no concentrated sweets with a good appetite with regular textured food and regular fluids. Resident #50 was noted to be allergic to tomatoes, potatoes, citrus and bananas due to her renal diet. The DM noted Resident #50 was on dialysis on M-W-F she takes a snack lunch meal with her each treatment. She is on a NCS diet but does no [sic] adhere to her diet. She a BLE amputee Her weight in Oct was 198.4 [DATE] & [DATE].6. Review of Resident #50's Annual Dietician Nutritional Assessment evaluations dated 12/07/2023 revealed an assessment. Review of nursing progress noted dated 11/01/2024 revealed Resident #50's blood sugars have been running low lately and resident's appetite has been poor. Notified [PHYSICIAN]. Received new order from [PHYSICIAN] to decrease Semglee (insulin) to 18 units daily. MAR updated to reflect changes. Review of nursing progress note dated 11/01/2024, 10/31/2024, 10/28/2024 (same note all three days) revealed Resident #50 appetite and fluid intake vary. Mainly fair and requires multiple reminders and offerings of her favorite foods to ensure she is taking in enough to maintain her blood sugar. Review of Diet Orders Policy and Procedure (undated) revealed when there is a nutritional indication, the facility will provide a therapeutic diet that is individualized to meet the clinical needs and desires of the resident to achieve outcomes/goals of care. Review of Diet Changes Policy and Procedure (undated) revealed nursing and therapy services is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 13 of 19 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 11/14/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm responsible for notifying the dietary department of any changes in the resident's diet, meal service, eating habits, and/or changes in the resident's condition. The policy further noted Nursing or therapy service staff is responsible for notifying the dietary manager when a nutritional problem has been identified (e.g., weight loss, pressure ulcer, eating problems, etc.). Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 14 of 19 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 11/14/2024 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 0759 Ensure medication error rates are not 5 percent or greater. 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 medication error rate was not five percent or greater when the facility had a medication error rate of 9.68% based on 3 of 31 opportunities, which involved 2 of 5 residents (Resident #39, and Resident #63) and 1 of 2 MA's (MA D) observed during medication administration. Residents Affected - Some A) Resident #39 had physician orders for Lisinopril 20 mg one tablet by mouth two times a day hold if BP is below 100/60 mm/hg and Metoprolol Tartrate 25 mg give 0.5mg tablet by mouth two times a day to keep pulse in normal range of 60 to 60 and to hold if BP was below 100/60 or pulse 55 bpm. MA D did not check Resident #39's vital signs prior to administering her medication on 11/13/2024 and no blood pressures were documented for November 2024. B) Resident #63 had a physician order for Midodrine HCL 2.5mg by mouth two times day and hold for BP greater than 140/80 mm/hg. MA D did not check Resident 63's vital signs prior to administering her medication on 11/13/2024. These deficient practices could place residents at risk of not receiving therapeutic dosage of medications and symptomatic changes in vital signs. Findings included: A) Review of Resident #39's face sheet reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses essential hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body.), and tachycardia (an irregular electrical signal, called an impulse, starts in the upper or lower chambers of the heart. This causes the heart to beat faster.). Review of Resident #39's annual MDS dated [DATE] reflected she was assessed to have a BIMS score of 4 indicating severe cognitive impairment. Resident #63 was assessed to have hypertension and atrial fibrillation or other dysrhythmias. Review of Resident #39's comprehensive care plan reflected a focus area dated 05/23/2023 I have diagnosis of hypertension. Interventions included, administer my antihypertensive medication as ordered, and obtain and evaluate my blood pressure as appropriate. Further review reflected a focus area I have coronary artery disease . Interventions included, administer my medications as ordered by my physician .I need my vital sings watched as ordered by my physician and as needed . Review of Resident #39's consolidated physician orders reflected an order dated 10/08/2024 Lisinopril 20 mg one tablet by mouth two times a day related to essential hypertension hold if BP is below 100/60 mm/hg. Further review reflected an order for Metoprolol Tartrate 25 mg give 0.5mg tablet by mouth two times a day related to essential hypertension to keep pulse in normal range of 60 to 60. Hold if BP is below 100/60 or pulse 55 bpm. Review of Resident #39's MAR dated November 2024 reflected an entry for Lisinopril 20 mg give one tablet by mouth two times daily hold if BP is below 100/60 mg/hg. No blood pressures were documented on the MAR. Further review reflected an entry for Metoprolol tartrate 25 mg give ½ tablet two times daily to keep pulse in normal range of 60 to 60 bpm; hold if BP is below 100/60 or pulse 55 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 15 of 19 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 11/14/2024 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 0759 bpm. No BP or pulse were documented on the MAR. Level of Harm - Minimal harm or potential for actual harm Observation on 11/13/2024 at 8:12 AM revealed MA D preparing to administer medications to Resident #39. MA D prepared her morning medications that included her Lisinopril 20 mg and Metoprolol Tartrate 25 mg. MA D administered her medication without taking her vital signs. Residents Affected - Some B) Review of Resident #63's face sheet dated 11/13/2024 reflected a [AGE] year-old female admitted to the facility 03/20/2023 with the following diagnoses Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), traumatic subarachnoid hemorrhage with loss of consciousness and syncope and collapse. (Bleeding in the space below one of the thin layers that cover and protect your brain.) and syncope (also known as fainting). Review of Resident #63's quarterly MDS dated [DATE] reflected Resident #63 was assessed to have a BIMS score of 3 indicating severe cognitive impairment. Resident #63 was further assessed to have cardiac implants. Review of Resident #63's comprehensive care plan dated 03/20/2023 and revised 07/31/2024 reflected no entry related to syncope or orthostatic hypotension (decreased blood pressure upon standing). Review of Resident #63's consolidated physician orders reflected an order dated 05/24/2024 Midodrine HCL (This medication is used for certain patients who have symptoms of low blood pressure when standing.) 2.5mg by mouth two times day for traumatic subarachnoid hemorrhage with loss of consciousness hold for BP greater than 140/80 mm/hg. Review of Resident #63's MAR dated November 2024 reflected an entry for Midodrine HCL 2.5mg by mouth two times day for traumatic subarachnoid hemorrhage with loss of consciousness hold for BP greater than 140/80 mm/hg. No blood pressure readings were documented on the MAR. Observation on 11/13/2024 at 8:10 AM revealed MA D preparing to administer medications to Resident #63. MA D prepared her morning medications that included her Midodrine HCL 2.5mg. MA D administered Resident #63's medication without taking her vital signs. In an interview on 11/13/2024 at 9:11 AM MA D stated she did not take Resident #39 or Resident #63 blood pressure or pulse prior to administrating their medication because the MAR did not indicate their vital signs needed to be taken. She stated Resident #39 and #63's orders indicated she needed to take Resident #39's blood pressure and pulse prior to giving the medications Lisinopril and Metoprolol and she should have taken Resident #63's blood pressure prior to administering the Midodrine. MA D stated when the orders were put in by the nurses. They did not put in the orders right (correctly) and the vital sign indicator did not show up on the system and that was why she missed it. In an interview on 11/13/2024 at 10:50 AM the DON stated that staff should absolutely be checking the blood pressures and vital signs on resident with parameters in their orders. She stated she would check all the orders to see that the orders were put in, so the vital sign indicators show up when staff are administering the medications. In an interview on 11/14/2024 at 12:46 PM the DON stated it was her expectation that staff give residents their medications per MD orders and that they follow medication parameters. She stated the failure of staff to do so could cause negative outcomes in residents such as blood pressure drops, or heart rate changes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 16 of 19 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 11/14/2024 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 0759 Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy Medication Regimen review not dated that was provided by the facility reflected .9. Each resident's medication regimen shall be reviewed to ensure it is free from unnecessary medications. A medication shall be considered unnecessary when it is used: .c. Without adequate monitoring . The facility's provided policy did not address medication administration using vital signs parameters. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 17 of 19 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 11/14/2024 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 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 under sanitary conditions in the facility's kitchen and nourishment room. Residents Affected - Some -The facility failed to ensure food and beverages stored in the walk-in cooler were labeled and dated. -The facility failed to remove the scoop for dry goods stored in large bins for sugar, flour, and thickener powder on 10/14/2024. -The facility failed to clean and sanitize the resident nourishment room refrigerator which had expired foods and an unknown brown substance in a bag. These failures could place residents who ate food from the kitchen, nourishment refrigerator and ice machine at risk of foodborne illness. Findings included: An observation in the kitchen on 10/12/2024 at 9:10 AM reflected unlabeled salad dressing in small containers, opened juice and milk in cups with lids with no label and date in the walk-in cooler. An observation in the kitchen on 10/12/2024 at 9:15 AM reflected a scoop in the container with sugar in it. In addition, there was a scoop in the flour container and thickener meeting. An observation on 10/13/2024 at 2:42 PM reflected expired yogurt in the nutrition refrigerator on the 100 hallway. In addition, there was a plastic bag with a brown substance inside that was not labeled and dated. In an interview on 10/14/2024 at 10:05 AM the DM stated all foods in the walk-in cooler should be labeled and dated when added to the walk-in cooler. She stated they only keep leftovers three days from the date it was added to the cooler. She stated if a food or drink was not labeled and dated, it could expose residents to food borne illness if served to a resident. She stated the scoops should not be in the bulk foods in bins like the flour, sugar and thickener powder. She stated leaving the scoops in the food could expose residents to germs on the staff's hands and cause food borne illness. She stated the nursing staff maintain the refrigerators in the nutrition rooms on the hallway. She stated there should not be expired foods or unlabeled/dated foods. She stated if these undated, unlabeled liquids and food were served to a resident it could cause food borne illness. In an interview on 10/14/2024 at 11:15 AM, the DON stated the scoops in the bulk food bins could cause food borne illness. She stated the scoops should not be stored in the container with the sugar, flour and thickened powder. She stated the foods in the walk-in cooler and nutrition refrigerator on hallway 100 should not be expired and should be thrown out if they are expired. She stated serving expired foods could cause food borne illness in residents. She stated staff should label and date foods according to policy. She stated expired or outdated foods should be thrown away immediately. She stated floor staff were responsible for cleaning and maintaining the nutrition refrigerator on the hallway and should have removed the expired food and the unlabeled/undated foods. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 18 of 19 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 11/14/2024 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 - Some In an interview on 10/14/2024 at 11:30 AM, the ADMIN stated staff should follow the policy for labeling and dating foods stored in the kitchen and nutrition refrigerators. He stated the scoops should not be stored in the bulk foods as it would cause food borne illness in residents. He stated the nutrition refrigerator on hallway 100 was cleaned and the expired foods were thrown away. Review of Food Safety and Sanitation Policy and Procedure (undated) revealed for food storage All time and temperature control for safety (TCS) leftovers are labeled, covered and dated when stored. They are used within 72 hours (or discarded). In addition, Foods with expiration dates are used prior to the use by date on the package. Review of FDA Food Code 2022 revealed scoops may be stored in a clean, protected location if the utensils such as ice scoops, are used only with a food that is not time/temperature control for safety food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 19 of 19