Health inspection·July 14, 2025

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few this resident nasal cannula back in her nares and raised her head. At this time a blood pressure was unable to be obtained and this resident O2 sat was 55%. After applying the nasal cannula 02 raised to 82%. Resident stated call 911, Help Me. This nurse then contacted EMS services and the arrived at 6:29 pm. Resident was transferred to stretcher and exited the facility with 3 attendants at 6:43. Resident RP and DON was also notified of situation. Signed by LVN A.Record review of Resident # 1 nursing progress note dated 7.5.25 at 5:51 am reflected Received report of resident returning to facility from an ER visit following cardiac arrest. No new orders, oxygen via NC at 6L. Resident arrived at facility via EMT services, with 2 EMT personnel, and [family]present. Resident is awake, alert answering few questions.No s/s of pain or distress noted. Resident remains on hospice, DNR, and wishes from RP of no lifesaving interventions. Signed by LVN B.Record review of Resident # 1 hospice binder reflected outside front of binder with sheet stating Call the Nurse First. We may be able to help you avoid unplanned hospitalizations if we know you need our help. Call the nurse first at the number listed below. Hospice provider name and contact number listed. On call 24 hours a day, seven days a week, including holidays. Further review reflected copy of OOH-DNR dated 6.17.25 accurately completed. Review reflected a red sheet of paper with a stop sign symbol stating hospice patient Do Not Resuscitate hospice provider name and contact information. Review of hospice certification and plan of care dated 6.18.25 reflected under orders of discipline and treatment heading:*SN TO INSTRUCT FACILITY STAFF ON HOSPICE RESPONSIBILITIES, 24/7 AVAILABILITY, HOW TO CONTACT HOSPICE, AND FACILITY STAFF RESPONSIBILITIES RELATED TO PATIENT CARE NEEDS AS DELINEATED ON THE HOSPICE PLAN OF CARE *SN TO EDUCATE FACILITY STAFF THAT HOSPICE APPROVAL IS NEEDED PRIOR TO ANY NEW ORDERS AND TO CONTACT HOSPICE STAFF FOR ANY CHANGE IN PATIENT CONDITION.*SN TO INSTRUCT PATIENT/CAREGIVER ON MEDICATION REGIMEN AND SIDE EFFECTS. *SN TO INSTRUCT PATIENT/CAREGIVER ON HOW TO MAINTAIN A MEDICATION ADMINISTRATION RECORD. *SN TO ASSESS EFFECTIVENESS OF TREATMENT REGIMEN.SN TO ASSESS FOR PAIN AND POTENTIAL CAUSES*SN WILL INSTRUCT PATIENT/CAREGIVER ON ADMINISTRATION OF INHALATION THERAPIES AND CARE OF EQUIPMENT.*SN TO INSTRUCT PATIENT/CAREGIVER ON RESPIRATORY DISEASE PROGRESSION, COMMONS SIGNS/SYMPTOMS, AND MANAGEMENT OF DISEASE PROCESS/SYMPTOMS.*SN TO ASSESS PATIENT FOR SIGNS AND SYMPTOMS OF IMPAIRED RESPIRATORY FUNCTION, DIFFICULTY BREATHING AND DISEASE PROGRESSION.*SN TO ASSESS FOR SAFE AND APPROPRIATE USAGE OF OXYGEN.*SN TO ASSESS FOR ANXIETY AND POTENTIAL CAUSES. SN TO ASSESS EFFECTIVENESS OF TREATMENT REGIMEN.Record review of hospice provider call log dated 7.4.25 at 6:56 pm reflected patient complained of SOB and her respirations slow and unable to get blood pressure. Patient sent to hospital. Observation of camera recordings of Resident # 1 incident on 7.4.25 reflected 4 facility staff in Resident # 1 room observation of vitals being taken and Resident # 1 being assessed by facility staff. Further review reflected 3 EMS staff observed coming into Resident # 1 room chest compressions being initiated and Resident # 1 being prepped for transport.Interview on 7.14.25 at 10:20 am with Resident # 1's RP revealed they felt the facility was unsure of their own policy and procedures concerning hospice residents and residents with DNR's. RP stated when Resident #1 was unresponsive that the facility called EMS and treated her and sent her to the hospital prolonging her suffering even with a DNR in place. RP stated she; nor hospice; nor the DON were called until Resident #1 had left the facility with EMS. RP felt Resident #1 suffered thru living extra days because of actions taken by the facility. Interview on 7.14.25 at 3:10 pm LVN A stated she works 7a-7p shift. Been working at the facility 10 months. Received ANE and Resident Right trainings via CBT monthly training and in person monthly staff meeting as well as management team bringing off cycle in-service trainings around. LVN stated advance directives are in the electronic record keeping system. LVN A stated if a resident has a COC, then the nurse obtains vitals and assesses the resident. LVN A stated the nurse calls the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 2 of 4 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 07/14/2025 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few doctor if the resident was not hospice to obtain further instructions, if the resident was on hospice services, then the nurse calls the hospice company to obtain further instructions. LVN stated for Resident # 1 COC she obtained vitals and assessed then she called hospice and got the on-call reception. LVN A stated she waited fifteen minutes for the hospice nurse to return call during the wait LVN A stated she contacted the facility doctor who advised the nurse to contact EMS. LVN A stated she contacted EMS for transport. LVN A stated while resident was still in the parking lot with EMS, LVN A called hospice again and spoke to hospice nurse and hospice nurse told the LVN A she would meet resident at the hospital. LVN A acknowledged that the progress note in resident electronic record does not state hospice was contacted prior to contacting EMS and transferring resident from facility. Interview on 7.14.25 at 3:34 pm with Hospice on-call nurse revealed Hospice nurse stated she received a call from the hospice triage line on 7.4.25 at 7:00 pm stating that Resident # 1 was SOB and unable to obtain a BP and that resident was sent out to the hospital. Hospice nurse stated she then contacted the facility and confirmed from LVN A that the resident had a COC was found SOB and unable to locate a BP and at that time EMS was called and resident was sent out. Hospice nurse inquired if the RP had given permission for transport. Hospice nurse stated charge nurse was unable to give an answer as to why resident was sent out prior to receiving authorization from hospice or RP. Attempted telephone interview on 7.14.25 at 4:15 pm with facility doctor no answer message left awaiting return call.Interview on 7.14.25 at 5:00 pm the DON stated she has worked at facility 3 1/2 years. DON stated if a resident has a COC, then the charge nurse was to go down and assess the resident. DON stated if the resident was on hospice the charge nurse was to notify the hospice company to attain further instructions. DON stated if the matter was emergent then the charge nurse does not transfer a resident until instructed by hospice. DON further stated that the charge nurse was to perform any treatments or give any medications the resident has that can be beneficial until transfer can be arranged, or further instruction was received from the MD, NP, or hospice. DON stated after notifying the MD, NP, or hospice then the nurse was to notify the DON, and RP of a COC. DON stated if a hospice resident was transported to the hospital prior to receiving approval from hospice it could negatively affect a resident emotionally, and psychologically due to having to endure unnecessary treatment and trips. DON stated nursing was to document everything patient related in the electronic record keeping system. DON stated if something was not documented then there was no proof it occurred. DON stated she was responsible for ensuring the nursing staff document resident information accurately. Interview on 7.14.25 at 6:05 pm with ADM revealed ADM stated he expected the nurse to attend the resident first, then notify hospice as soon as possible. ADM stated he does not feel the situation was handled wrong or right. ADM stated EMS was called for resident treatment and EMS make the decision to transport. ADM stated he does not feel the resident was transported unnecessarily as the resident just needed stabilizing and suffered no ill effects. ADM stated he feels hospice residents should have hospice contacted first. ADM stated he feels the nurse made the right decision in a split-second type of situation. ADM stated his expectation was that nursing document resident information. ADM stated he feels the facility systems did not fail but that the processes just need to be fine-tuned. ADM stated ultimately the responsibility of nursing training and documentation was the ADM responsibility. Record review of in-service dated 7.8.25 titled Guidelines/Parameters related to When to send hospice resident to the ER and when not to. Calling hospice service conducted by hospice provider with 9 staff attendance signatures. Supporting documentation provided from hospice provider. Record review of supporting documentation from in-service dated 7.8.25 reflected:Call Hospice, not 911Supporting hospice patients with dignity in the nursing homeWhen hospice patient declines call hospice first. If (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676174 If continuation sheet Page 3 of 4 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 07/14/2025 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete a resident is under hospice care is physically declining, calling 911 may not align with their end-of-life goals. We are available 24/7 to manage symptoms and provide guidance at the bedside, helping patients remain in comfort and dignity right where they are-home.Why not call 911? Hospital transfers are often painful and disorienting.ER visits can prolong suffering and may lead to interventions the patient didn't want.Calling 911 may go against the patients wishes and care plan.What to do instead:Call hospice provider first:-Our nurses will triage the situation and come to the facility if needed.-We manage most symptoms directly in the nursing home.Call the family:-Keep them informed and calm.Treat symptoms if appropriate:- Use hospice approved PRN medications.- Follow the hospice plan of care and consult with hospice nurse as needed.Record review of facility Residents Receiving Hospice Services policy undated reflected under heading procedure:1. When a facility resident has also elected the Medicare hospice benefit, the hospice, and the nursinghome must communicate, establish, and agree upon a coordinated plan of care for both providers which reflects the hospice philosophy, and is based on an assessment of the individual's needs and unique living situation in the facility.2. The plan of care must include directives for managing pain and other uncomfortable symptoms andbe revised and updated as necessary to reflect the individual's status.3. This coordinated plan of care must identify the care and services which the nursing facility and hospicewill provide to be responsive to the unique needs of the resident and their expressed desire forhospice care.4. The nursing facility and the hospice are responsible for performing each of their respective functionsthat have been agreed upon and included in the plan of care.5. The hospice retains overall professional management responsibility for directing the implementationof the plan of care related to terminal illness and related condition.Record review of facility Hospice benefit care requirements policy undated reflected under heading procedure:For a resident receiving hospice benefit care4. The plan of care must include directives for managing pain and other uncomfortable symptoms [NAME] revised and updated as necessary to reflect the resident's status.6. The hospice and the facility will communicate with each other when any changes are indicated to theplan of care. Record review of facility Advance directives policy undated reflected under purpose:To ensure every resident has the opportunity to make an informed decision regarding their advanced directives.Under heading policy:Advance directives will be respected in accordance with state law and facility policy.Under heading procedure:15. In accordance with current OBRA definitions and guidelines governing advance directives, our facility hasdefined advanced directives as preferences regarding treatment options and include, but are not limited to:e. Do Not Resuscitate - indicates that, in case of respiratory or cardiac failure, the resident, legalguardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonaryresuscitation (CPR) or other life-sustaining treatments or methods are to be used. Event ID: Facility ID: 676174 If continuation sheet Page 4 of 4