Inspection·November 2, 2022

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/02/22 at 08:19 AM LVN B stated prefilled humidifier should be changed weekly. It is done on night shift on Sunday. LVN B stated she did not realize Resident # 39 prefilled humidifier had not been changed on the days she worked. The risk to the resident could be infections and discomfort. During an interview on 11/02/22 at 08:32 AM DON stated the night nurses are responsible for changing the prefilled humidifier bottles. DON and ADON are responsible for overseeing that the night nurses are following the policy. DON did not know why the prefilled humidifier water was not changed with the oxygen tubing. The risk to the resident could be infection control and discomfort if the humidifier is out of water. Record review of undated policy titled, [facility name] Nursing Departmental (Respiratory Therapy) Prevention of Infection Policy stated, .infection control consideration related to oxygen administration #3 prefilled sterile humidification water bottle will be marked with date and initials upon opening and changed and discarded every 7 days and prn . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 2 of 12 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 676344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacies Nursing and Rehabilitation 355 Fm 83 W Hemphill, TX 75948 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 2 of 2 medication carts (nurse cart for halls 100/200 and 300/400). The facility did not dispose of expired insulins for Resident #76 and glucose control solutions from the nurse medication carts for halls 100/200 and 300/400. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications, decreased quality of life, and hospitalization. Findings included: 1.During an observation, and interview on 10/31/22 at 10:15 am with LVN C the medication cart for 100/200 hall contained Assure Prism Glucose Control Solution High and Low with a discard date of 10/20/22, (no opened date) LVN C said I will take that out and dispose of it. LVN C said she did not know the solution had expired and the night staff perform glucometer checks nightly and provided the logbook. LVN C said the Glucose solution should be replaced because they are only good for 28 days dates depending on manufacturer. Record Review of the Glucometer High/Low solution log indicated control Lot #CSTU28BN was opened in July 15,2022 and logged in use for the months of August 2022, September 2022 and logged as being used from 10/01/22 until 10/31/22. 2. During an observation and interview on 10/31/22 at 10:30 am with LVN D for medication storage and labeling on the 300/400 Hall LVN cart, the cart had an opened Insulin vial dated 09/21/22, indicating the insulin expired 28 days later on 10/19/22. LVN D said, Resident #76's Insulin should have been discarded. LVN D said if the vials of insulin were not labeled with the date it was opened and discarded after 28 days it could affect to efficiency or potency of the insulin and the insulin should be discarded 28 days from removing the cap. LVN D said Resident #76 gets a FSBS after meals and every HS with sliding scale insulin to cover the value of glucose. Review of MAR for October 1 to October 30, 2022, there had been no glucose value requiring coverage since 10/07/22. LVN D said Resident #76 remains at risk due to the existing order for sliding scale coverage and that the insulin should be discarded and reordered. Record Review of Monthly order summary dated 10/01/22 indicated Resident #76 with an initial admission date 12/09/21, readmission date of 02/04/2022 with a date of birth [DATE] age [AGE]. Dx. COPD, Depression and Diabetes. Order for Novolog Solution 100 Unit per ml inject as per sliding scale before meals and at bedtime related to Type Two Diabetes ( High Blood Sugar) with other specific complications: If glucose per finger stick blood sugar is 200-250=give 2 units; 251-300= give 4 units; 301-350= give 6units; 351-400=give 8units;401-451=give 10units; if over 400 give 10 units and notify MD. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 3 of 12 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 676344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacies Nursing and Rehabilitation 355 Fm 83 W Hemphill, TX 75948 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an Interview on 10/31/22 at 10:45 am the DON said she would provide the policy for glucose monitoring and checks, multi-dose vials and insulin. The DON said that the expired controls in the 100/200 cart should have been discarded on 10/15/22, 90 days after they were opened and logged for use on July 15, 2022. The DON said the Insulin vials should be discarded after 28 days after opening since the efficiency could be affected. The DON said she is responsible for ensuring medications carts did not contain expired medications and the night staff perform the cart checks and she monitors them also. During an interview on 11/02/22 at 11:20 am with the Administrator, she said the DON was responsible for oversight of the medication storage and labeling. A review of L. Novolog Insulin Solution 100 Unit/ML had a use by date of 28 days from opening www. Lilly.com accessed on 10/31/22. and Assure Prism Glucose Control Solutions and Test strips 90 days after opening at www. assureglucometers.com accessed on 10/31/22. A review of Insulin Administration Policy Revised 2014 Purpose: To provide guidelines for the safe administration of insulin to residents with diabetes. Steps in the procedure (Insulin injections via syringe) 4. Check Vial of for expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time on the vial (follow manufacturer's recommendations for expiration after opening). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 4 of 12 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 676344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacies Nursing and Rehabilitation 355 Fm 83 W Hemphill, TX 75948 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 ensure food was stored, prepared, and distributed under sanitary conditions in 1 of 1 kitchen. Residents Affected - Some The DM used the wrong test strips, (QT40 Strips) instead of chlorine test strips to test the sanitizer level (ppm) in the low temperature dish machine. The dish machine would only reach 118 degrees F after three cycles, and not the manufacturer's recommendation temperature of 120 degrees F. The October 31, 2022, Dish Machine Temperature & Chemical Logs, were pre-filled for lunch and dinner before the meals occurred. There were chicken strips, biscuits, and French fries in the freezer in clear bags with no label. These clear bags were removed from the original manufacture's box and had no labels on the bag indicating what was in the bag, date received, use by date, or expiration date. The beef broth in the refrigerator was expired with an expiration date of 09/24/22. The dietary aide licked her fingers to separate the tray cards, while setting up trays on the serving line. She then picked up the tea glass, the silverware and straw and placed these items on the resident's tray. These failures could place residents who consumed food prepared from the kitchen at risk of food-borne illness. Findings Include: During an observation on 10/31/22 at 9:20 a.m., the DM tested the low temperature dish machine's chlorine level (ppm) with Quaternary Sanitizers (QT40) test strips. These test strips were indicated for testing the concentration of Quaternary Sanitizers, particularly multi-quat broad range quaternary ammonium sanitizer solutions and not the (PPM) of sanitizing solutions required for their low temperature machine. The dish machine only reached 118 degrees F after three cycles, instead of required manufacture's recommended water temperature of 120 degrees F. The Dish Machine Temperature & Chemical Log had been prefilled for lunch, and dinner at 9:20 a.m During an observation on 10/31/22 at 9:30 a.m., the following was observed in the freezer: There were frozen chicken strips, biscuits, and French fries in clear plastic bags with no label indicating the date received, or use by date. There were slices of cheese with a received date of 10/21/22, there is no use by date on the bag. There was beef broth in the refrigerator that had expired of 9/24/22. During an interview on 10/31/22 at 9:45 a.m., with the DM she said she had only been working as the DM for a month. She said she texted the service man to find out what test strips she needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 5 of 12 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 676344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacies Nursing and Rehabilitation 355 Fm 83 W Hemphill, TX 75948 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 (Chlorine test strips) Level of Harm - Minimal harm or potential for actual harm During an interview on 10/31/22 at 10:00 AM with the ADM she said they had not had an onsite registered dietician in 3 months, she said the company they were using only provided an off-site dietician. She said she had been trying to find someone to come to the facility and help the new DM. She said they had not been able to find anyone in this area. She said the DM has only been in the position for one month and has not completed the DM certification course. She said she thought there was a waiver for the dietary manager course because no one wants to take the course. Residents Affected - Some During an interview on 10/31/22 at 10:11 a.m., with the ADM, she said her expectations for the kitchen was for all items in the kitchen to be labeled with date received, use by date, and proper manufactures expiration dates. She said that not discarding foods by the expiration date, could cause the residents to get sick. She said she expects the DM to make sure the dietary staff are labeling food items per policy and checking expiration dates on foods in the refrigerator and freezer. During an interview on 10/31/22 at 11:38 a.m., with the DM she said she had not completed the Texas Certified Food Manager course. She said the staff in the kitchen were supposed to label and date the items in the refrigerators and freezers, that includes the date received and use by date. The DM said she did not realize that when the staff removed the bags from the boxes they are received in, there were no label or expiration dates on the packages. She said she had talked to the ADM and the kitchen staff are to check the refrigerators/freezers for expiration date on all foods every morning. During an interview on 10/31/22 at 12:15 p.m., the ADM she said she would get someone out to check the dish machine temperature today and make sure they had the proper test strips and dietary staff were trained to use them. During an observation on 11/01/22 at 11:45 a.m., of the serving line dietary aide H was observed licking her fingers to separate the tray cards. She then picked up the drink glass, dessert, silverware, and condiments, and placed them on the resident's tray after licking her fingers. During an observation on 11/01/22 at 11:46 a.m., of the serving line dietary aide H licked her fingers again to pick up a tray card, then picked up drinks, dessert, silverware, and condiments to place on the resident's tray. During an observation on 11/01/22 at 11:55 a.m. dietary aide H, was observed with a resident's tray card in her mouth while retrieving items from the fridge, and then placed tray card on a resident's tray, and continued to load trays. During an interview on 11/02/22 at 11:36 a.m. with dietary aide H she said she was stressed out and nervous so she made a mistake when she licked her fingers. She said she realizes that licking her fingers and touching the items on the trays, could make the residents sick. During an interview on 11/02/22 at 11:41 a.m., with the DM, she said she is still learning. She said the ADM., is trying to find a RD who will come to the facility. During a record review on 11/02/22 at 11:45 a.m., of a policy titled Food Receiving and Storage, revised 12/2008, indicated all food stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). Such food will be rotated using a first in-first out system. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 6 of 12 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 676344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacies Nursing and Rehabilitation 355 Fm 83 W Hemphill, TX 75948 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 During a record review on 11/02/22 at 12:00 p.m., of a policy titled Refrigerators and Freezers revised December 2008 indicated: 7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is open. 8. Supervisors will be responsible for ensuring food items in pantry, refrigerators and freezers are not expired or past parish dates. Supervisors should contact vendors or manufacturers when expiration dates are within question or to decipher codes. During a record review on 11/02/22 at 12:15 p.m., of a policy titled Dishwashing Preparation and Dishwashing indicates: 2. Automatic dishwasher; Low temperature machine c. The was cycle shall be at least 40 seconds with a temperature of 120 degrees F in dish machine. The sanitizing rinse period shall be at least 20 seconds with minimal water temperature of 120 degrees F. d. Prior to washing the soiled dishes after a meal the dish machine shall be tested for proper temperature and PPM of sanitizing solution. The dish machine may need to be ran empty for a couple of cycles to ensure the proper temperature is attained, and no dishes will be washed prior to achieving this standard. h. Facilities shall use the appropriate test kit to measure the parts per million (ppm) of the chemical solution in the dish machine on a daily basis. Any abnormal test result shall be reported to the Dietary Manager. A ppm of 50 will be attained prior to dishes being washed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 7 of 12 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 676344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacies Nursing and Rehabilitation 355 Fm 83 W Hemphill, TX 75948 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. 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 safe and sanitary storage of resident's food items for 1 of 3 resident personal refrigerators reviewed for food safety (Residents #12). Residents Affected - Few The facility did not implement the personal food policy related to personal refrigerators for Resident #12. The refrigerator for Resident #12 contained food items that were expired. This failure could place the residents at risk for food borne illnesses. The findings included: Record review of an admission Record for Resident #12 dated 11/2/2022 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of type 2 diabetes, iron deficiency anemia (low iron in the blood) major depressive disorder (persistent feeling of sadness and loss of interest), atherosclerosis (hardening of the arteries) and PVD (narrowed blood vessels in the legs). Record review of a Quarterly MDS Assessment for Resident #12 dated 9/23/2022 indicated he did not have any impairment in thinking with a BIMS score of 15. He required supervision with eating, toilet use and personal hygiene with set up help only. Record review of the most current Care Plan for Resident #12 completed on 10/3/2022indicated he had an ADL self-care performance deficit. He had a personal refrigerator in room. Intervention included was that housekeeping would check his refrigerator weekly for outdated foods and discard. During an observation on 10/31/2022 at 10:39 AM of Resident #12's personal refrigerator in his room revealed 1 bottle of Miracle Whip with an expiration date of 11/11/2020, 1 bottle of Parkay butter with an expiration date of June 2021, a container of Country Crock butter with an expiration date of 4/17/22, 1 strawberry yogurt with an expiration date of 4/30/22, 1 can of tomato juice with an expiration date of 3/23/22, 2 fruit cups with an expiration date of 10/02/18, and 1 jar of horseradish with an expiration date of 11/09/15. During an observation and interview on 10/31/2022 at 11:45 AM, Resident #12 was present in his room eating lunch, said he had been at the facility for quite some time. He said the housekeepers were responsible for checking the temperatures and removing expired food items from his refrigerator. He said he did not know he had expired items in his refrigerator. During an interview on 11/01/2022 at 9:01 AM, HSK J said she had been employed at the facility since March 2022 but has been in housekeeping since August 2022. She said she was responsible for checking the personal refrigerators every Friday along with cleaning them out, defrosting and recording temperatures in a logbook on the housekeeping cart. She said Resident #12 would refuse most times and not allow staff to clean out his refrigerator. She said she did not know he had multiple foods that were expired. She said the housekeepers were also responsible for throwing away stuff that was out of date. She said if a resident ate food that were expired it could make them sick. During an interview on 11/1/2022 at 2:20 PM, the Administrator said she was not aware that Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 8 of 12 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 676344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacies Nursing and Rehabilitation 355 Fm 83 W Hemphill, TX 75948 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 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete #12 had multiple expired food items in his personal refrigerator. She said she had a talk with him earlier and told him if he did not allow the staff to clean out his personal refrigerator, then he would be told to do it himself. She said he agreed to allow the housekeeping staff to do it and check every Friday. A Facility Policy Titled Personal Property undated indicated, .Resident are permitted to bring personal property and use personal possessions to create a home-like environment. 3. Small appliances are allowed by: B. Personal refrigerators 4. Housekeeping staff will clean and temp each refrigerator once a week if resident does not agree to housekeeping cleaning refrigerator they or family must agree to check and clean weekly. 5. Staff must discard food from refrigerators that show obvious signs of potential foodborne danger, and/or is beyond expiration date . Event ID: Facility ID: 676344 If continuation sheet Page 9 of 12 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 676344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacies Nursing and Rehabilitation 355 Fm 83 W Hemphill, TX 75948 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 0880 Provide and implement an infection prevention and control program. 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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 5 CNAs (CNA E, CNA G and CNA I) reviewed for infection control. Residents Affected - Some CNA E did not change gloves and perform hand hygiene when providing incontinent care for Resident #14. CNA G did not wash or sanitize her hands when changing gloves while performing incontinent care for Resident #37. CNA I did not wash or sanitize her hands when changing glove while performing incontinent care to Resident #66. These failures could place residents at risk for infections from improper incontinent care. Findings include: 1. Record review of face sheet dated 11/2/2022 indicated Resident # 14 was admitted to the facility on [DATE] with diagnoses Dementia (poor memory), colon cancer, and mood disorder. Record review of MDS dated [DATE] indicated Resident # 14 had a BIMS score of 06 indicating severely impaired cognition and required extensive assistance of one person for toileting. Record review of care plan dated 09/09/2022 indicated Resident # 14 has an ADL self-care performance deficit and required extensive assistance of 1 person for toileting. During and observation on 11/02/22 at 9:34 am Resident # 14 received incontinent care provide by CNA E and CNA F. Prior to incontinent care both CNAs gathered the needed supplies, sanitized their hands, and donned (applied) gloves. Resident # 14 was positioned by CNA E and soiled brief removed. Incontinent care provided to front peri-area using 6 wipes and wiping front to back by CNA E. Resident # 14 was then positioned on her left side by CNA F and CNA E cleaned the buttocks. CNA E then removed soiled brief, placed a clean brief and clean incontinent pad without changing gloves or hand hygiene. CNA E then adjusted resident bed and linen with same soiled gloves. CNA E and CNA F then removed gloves and sanitized hands before leaving room. During an interview on 11/02/22 10:00 AM CNA E stated she should have changed her gloves and performed hand hygiene when going from soiled brief to clean brief and before handling resident linen. Stated she had been trained and just had a training with a check off a month ago. CNA E stated the risk to the resident would be infections. During an interview on 11/02/22 at 10:14 AM DON stated that she had a training on 9/30/2022 regarding incontinent care, infections, hand hygiene and urinary tract infections with a return demonstration from all CNA's. DON stated CNA E received the training and successfully demonstrated competency. DON stated the risk would be infection control. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 10 of 12 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 676344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacies Nursing and Rehabilitation 355 Fm 83 W Hemphill, TX 75948 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of in-service training dated 9/30/2022 indicated CNA E received training regarding incontinent care, urinary tract infections, hand hygiene and infection prevention. 2. Record review of an admission Record dated 11/2/2022 for Resident #37 indicated she was [AGE] years old with diagnoses of bipolar disorder (mood swings), COPD (a group of lung diseases), GERD (reflux disease) Dementia (trouble remembering and making decisions) and hypertension (high blood pressure). Record review of a Significant Change MDS assessment dated [DATE] for Resident #37 indicated she had moderate impairment in thinking with a BIMS score of 9. She required extensive with bed mobility, transfers, dressing, toilet use and personal hygiene with 1-2 person assist. She was always incontinent of bowel/bladder. Record review of a Care Plan for Resident #37 with a last care plan review completed on 8/5/2022 indicated she had bladder incontinence with an intervention for incontinent care at least every 2 hours and apply moisture barrier after each episode. Record review of an in-service dated 9/30/2022 on Infection Control, Peri Care, UTI's, and Foley Cath Care by the DON indicated that CNA was in attendance with her signature noted on sign in sheet. During an observation on 11/01/2022 at 9:12 AM, CNA G and NA H were in Resident #37's room. Both washed their hands in the bathroom and gloves were applied to their hands. Resident #37's brief was opened and pulled down between her legs. CNA G removed a wipe from the plastic bag and wiped Resident #37's vaginal area from front to back on left side of her thigh. She placed the wipe in the trash. CNA G took another wipe and wiped Resident #37 on the right side of her vaginal area. CNA G placed the wipe in the trash and took another wipe and wiped down the middle of Resident #37's vagina from top to bottom. Resident #37 was rolled to her left side assisted by NA H and CNA G took a wipe and wiped her rectal area from front to back 4 times using 4 wipes. CNA G rolled the brief underneath Resident #37's buttocks and removed it. CNA G removed her gloves and placed them in the trash. CNA G placed gloves on her hands without washing or sanitizing them and placed a new brief underneath Resident #37's buttocks. Resident #37 was rolled to her right side being assisted by NA H. CNA G secured Resident #37's brief. CNA G removed her gloves and placed them in the trash. Resident #37 was covered back up with linens, repositioned back in bed in the lowest position. NA H removed her gloves and placed them in the trash. Both CNA G and NA H went into the bathroom and washed their hands. During an interview on 11/01/2022 at 9:29 AM, CNA G said she had been employed at the facility since June 2022. When asked if she would have done anything differently with the incontinent care performed on Resident #37, she said she was supposed to wash or sanitize her hands after she changed her gloves. She said she did receive training on handwashing at the facility upon hire and has had training since then. She said there was a risk for cross contamination if someone does not wash or sanitize their hands between glove changes. During an interview on 11/2/2022 at 10:10 AM, DON said CNA G had an in-service on 9/30/2022 at the facility on infection control, peri care, UTI's, and incontinent care that was conducted by her. She said the risk of staff not washing or sanitizing their hands between glove changes would be infections. 3. Record review of an admission Record for Resident #66 dated 11/2/2022 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Alzheimer's disease (progressive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 11 of 12 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 676344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacies Nursing and Rehabilitation 355 Fm 83 W Hemphill, TX 75948 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some disease that destroys memory), hypertension (high blood pressure), GERD (reflux disease), and diaphragmatic hernia with obstruction (opening in stomach wall. Record review of a Significant Change MDS dated [DATE] for Resident #66 indicated she was unable to complete the interview with a BIMS score of 99. She was always incontinent of bladder and bowel. She required extensive assistance with bed mobility, transfers, dressing, eating, toilet use and personal hygiene with one-to-two-person physical assist. Record review of a Care Plan for Resident #66 with last care plan review date of 10/26/2022 indicated she had bowel/bladder incontinence with interventions of incontinent care at least every 2 hours and apply moisture barrier after each episode. During an observation on 11/2/2022 at 9:16 AM CNA I was outside in the hallway of Resident #66's room gathering supplies to perform incontinent care. CNA I entered the room of Resident #66 and told Resident #66 that she would be providing incontinent care. CNA I pulled the linens back, applied gloves to both hands and pulled Resident #66's brief down between her legs. CNA I removed a wipe from the plastic bag and wiped both sides of vagina with a wipe and then took another wipe and wiped down the middle of Resident #66's vagina. CNA I then rolled Resident #66 to her left side and removed a wipe from the plastic bag and wiped from front to back a total of 6 times with 6 wipes. CNA I removed the brief and placed it in the trash. CNA I removed the glove from her left hand and placed it in the trash. CNA I then applied a glove to her left hand without washing or sanitizing her left hand. CNA I applied skin protectant ointment to Resident #66's buttocks with her left hand. Resident #66 was rolled back onto her back, and CNA I applied skin protectant ointment to both inner thighs and perineal area with her left hand. Brief was applied and secured. Resident #66 was positioned in bed. CNA I removed her gloves and placed them in the trash. CNA I then placed the linens back on Resident #66. CNA I exited the room and sanitized her hands. During an interview on 11/2/2022 at 9:25 AM, CNA I said she had been employed at the facility since December 2021. She said she should have sanitized or washed her hands between glove changes when asked if she would have done anything differently with the incontinent care provided to Resident #66. She said she had received in-services on hand washing and hygiene at the facility recently. During an interview on 11/2/2022 at 10:10 AM, DON said CNA I had an in-service on 9/30/2022 at the facility on infection control, peri care, UTI's, and incontinent care that was conducted by her. She said the risk of staff not washing or sanitizing their hands between glove changes would be infections. Record review of a facility policy titled Handwashing/Hand Hygiene with a revised date of August 2019 indicated, .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; m. after removing gloves . Record review of a facility policy titled Perineal Care with a revised date of February 2018 indicated, .The purpose of this procedure and to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. 9. Discard disposable items into designated containers. 10. Remove gloves and discard into designated container. 11. Wash and dry your hands thoroughly . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 12 of 12