Inspection·December 20, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm During an interview on 12/18/2023 at 12:00 PM, CNA G said she had been employed at the facility for 1 1/2 years. She said when the CNAs helped in the dining room with serving meal trays, they had to go into the kitchen before the mealtime and pull the tray cards for the residents who were eating in the dining room for that meal. She said staff from each hall were responsible for pulling their own tray cards. She said Resident #20's staff was CNA H who was assigned to that hall. Residents Affected - Few During an interview on 12/18/2023 at 12:15 PM, CNA H said that staff were to go into the kitchen before meals and pull the tray cards for the residents that were eating in the dining room. She said CNA J pulled the tray cards for hall 100 today. During an interview 12/18/2023 on 12:18 PM, CNA J said she pulled the tray cards to hall 100 today in the kitchen for the residents from the hall that were eating in the dining room. She said today 12/18/2023, most of the people that normally ate in the dining room from hall 100 were in the dining room at lunch. She said she pulled the tray cards for the residents on hall 100 that were eating in the dining room and placed them face down in the kitchen so the kitchen staff would know the residents were in the dining room. She said Resident #20 ate in the dining room daily and she did not know why she received her tray after everyone else in the dining room. During an observation and interview on 12/19/2023 at 8:37 AM, Resident #20 was in her room alert to person, place, and time. She said sometimes the staff forget to turn her meal tickets in. She said she ate all meals in the dining room except for breakfast. She said she believed the aides were responsible for turning her ticket in to the kitchen staff. She said she should not have been the last person to get her meal at lunch on 12/18/2023 and everyone else was eating and had already said their grace. She said sometimes they forget. During an interview on 12/19/2023 at 10:45 AM, the DM said the dietary helper would pull the tray cards and get the resident's drinks, silverware, and dessert, and pass it down the assembly line to the cook who would plate the food. She said the tray cards were assigned to the aides to pull so the kitchen staff would know which residents would be coming to the dining room for mealtime. She said Resident #20's tray card was not pulled and they did not know she was in the dining room for lunch yesterday. She said if staff let them know when they noticed someone had not received their meal tray or the tray cards were not pulled, then the kitchen staff would stop and prepare the meal tray for that resident. She said she would be angry if everyone was served their meal before her. She said the aides were responsible for pulling the tray cards so the kitchen staff would know who was eating in the dining room. During an interview on 12/20/2023 at 2:19 PM, the Administrator said that the CNAs and nursing staff were responsible for passing trays to the residents in the dining room. She said CNAs went into the dining room ahead of mealtimes and pulled the tray cards for the residents who would be eating in the dining room that day. She said the dining room staff relied on the tray cards that were pulled and prepared the meal trays for those residents in the dining room. She said Resident #20 had been sick and eating in her room prior to 12/18/2023 and the nurse aide for her hall forgot to pull her tray card that day. When asked how she would feel if that happened to her, she stated that she would want to eat when everyone had their food. She said going forward, the nurses were responsible for overseeing each meal and would ensure no one was left behind with getting their meal trays. 2.During an observation and interview on 12/18/23 at 12:10 pm CNA N was observed on 200 hall with resident doors open. CNA N said, we have a lot of feeders down this hall, she then repeated We have about 9-10 feeders down here. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 2 of 21 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 12/20/2023 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a joint interview on 12/19/23 at 12:10 pm, the Administrator and DON both said that the staff should know better than to refer to residents as feeders. The Administrator said that they would be doing in-services and she expected staff to not refer to residents as feeders in the future. She said that this was a dignity issue for the residents. During an interview on 12/19/23 at 12:15 pm, CNA N said that she did refer to the residents as feeders and she said that she knew she should not have done that because it could make the residents feel bad about themselves. Record review of a facility's policy titled Dignity with a revision date of February 2021 read .Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and ot labeling or referring to the resident by his or her room number, diagnosis, or care needs Record review of facility's policy titled Assistance with Meals dated March 2022 read .Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example .avoiding the use of labels when referring to residents (e.g., feeders) . Record review of a facility's policy titled Dignity with a revised date of February 2021 indicated, .Each resident shall be cared for in a manner that promotes and enhanced his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 3 of 21 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 12/20/2023 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 0554 Allow residents to self-administer drugs if determined clinically appropriate. 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 the interdisciplinary team had determined that self-administration of medications by a resident was clinically appropriate for 1 of 4 (Resident #34) residents reviewed for resident rights, in that: Residents Affected - Few The facility failed to assess, obtain physician orders, and interdisciplinary team approval for Resident #34 to self-administer his Ventolin inhaler. This failure placed the resident at risk of not receiving the proper medication or the therapeutic benefits of medications. Findings: Record review of facility face sheet dated 12/19/2023 revealed Resident #34 was a [AGE] year-old male that admitted to the facility on [DATE] for diagnosis of chronic obstructive pulmonary disease (COPD) (lung disease affecting breathing). Record review of a quarterly MDS assessment dated [DATE] revealed Resident #34 had a BIMS score of 15 indicating intact cognition. Record review of physician order dated 11/04/2019 revealed an order for Ventolin aerosol solution 90 mcg 2 puffs inhale orally every 8 hours as needed for COPD. The order did not indicate Resident #34 could self-administer. Record review of Resident #34's comprehensive care plan dated 11/20/2023 did not reveal a care plan was developed for Resident #34 to self-administer medications. During an observation and interview on 12/18/23 at 09:28 am. Resident #34 had a Ventolin inhaler at his bedside and stated he was safe to use his inhaler when he needed it and had an order to keep it on him. He stated the staff told him to keep it on him for safety and let them know when he needed a new one. During an interview on 12/19/23 at 10:29 am, LVN A stated Resident #34 was able to self-administer his inhaler and was deemed competent to do so. She stated if a resident was assessed to be able to safely self-administer medications, there should be an order and it should be put on their care plan. She stated she was not aware Resident #34 did not have an order or that it was not on his care plan. She stated if residents were self-administering medications without properly being assessed it could affect their wellbeing and receiving proper medication dose. During an interview on 12/19/2023 at 2:03 pm, the ADON stated she was responsible for completing the assessment and care plan for a resident to self-administer medications if they wished to do so. She stated Resident #34 should have had an order for self-administration of medications and it should have been on his care plan because he has expressed desire to use his inhaler when he needed it. She stated by not properly determining that resident could self-administer their meds could affect their overall health and medication effects. During an interview on 12/20/23 at 08:50 am, the DON stated the ADON was to complete the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 4 of 21 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 12/20/2023 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 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assessments on admission, quarterly and as needed for safe self-administration of medication. She stated if the resident was deemed safe, an order was obtained for self-administration of medication and the care plan was updated. She stated the charge nurse was responsible for monitoring the medication left at the bedside. She stated if residents were not accurately assessed, and the resident was self-administering medications it could cause adverse effects to medications. She stated she expected all residents to be accurately assessed for safe self-administration of medications before meds are left at the bedside. During an interview on 12/20/23 at 09:13 am, the Administrator stated nursing staff were responsible for assessing residents for self-administering medications. She stated the ADON assessed residents that wished to self-administer medications and if safe administration was determined there should be an order and IDT (interdisciplinary team) should do a care plan. She stated if a resident was not accurately assessed before self-administering medications, it could cause inappropriate medication administration and drug interactions. She stated she expected each resident to be accurately assessed and documented appropriately before allowing resident to self-administer medications. Record review of facility's policy titled Self-Administration of Medications dated February 2021 indicated, .if it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan . Record review of facility's policy titled Resident Self Determination and Participation dated August 2022 indicated, .self-administer medications if the IDT care planning team determines it to be safe . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 5 of 21 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 12/20/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change of condition for 4 of 6 Residents (Resident #49, Resident #56, Resident #67, and Resident #76) reviewed for PASSAR (Preadmission Screening and Resident Review Services) in that: 1. The facility failed to ensure Resident #49 had a PASSAR level II evaluation completed with a diagnosis of psychotic disorder (abnormal thinking and perceptions). 2. The facility failed to ensure Resident #56 had a new level 1 PASSAR completed with a new diagnosis of schizoaffective disorder, bipolar type (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). 3. The facility failed to ensure Resident #67 had a new level 1 PASSAR completed with a new diagnosis of Post-Traumatic Stress Disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations). 4. The facility failed to ensure Resident #76 had a new level 1 PASSAR completed with new diagnosis of psychotic disorder with hallucinations. These failures could place residents at risk of not receiving the needed PASSAR services to meet their individual needs and could result in a decreased quality of life. Findings: 1. Record review of an admission Record for Resident #49 dated 12/20/23 indicated she admitted to the facility on [DATE] and was [AGE] years old with a primary diagnosis of multiple fractures of pelvis, and other diagnoses included psychotic disorder, GERD (acid reflux) and dementia (a progressive or persistent loss of thinking). Record review of a Significant Change MDS assessment dated [DATE] indicated she had moderate impairment in thinking with a BIMS score of 8. She had diagnoses of non-Alzheimer's dementia, anxiety disorder, and psychotic disorder. A referral was not made to the local contact agency. Record review of a care plan for Resident #49 dated 7/28/2022 indicated she had impaired cognitive function/dementia or impaired thought processes. Record review of a physician order for Resident #49 dated 7/24/2023 indicated a new diagnosis of psychotic disorder with delusions was added. Record review of a PL1 (PASSAR Level I) for Resident #49 dated 6/13/2022 indicated she was not positive for MI, ID, or DD. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 6 of 21 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 12/20/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of a Form 1012 for Resident #49 dated 12/20/2023 indicated that she had a primary diagnosis of dementia and the PL1 remained negative and no new PL1 needed to be completed. The form did not have the required physician signature. 2. Record review of a facility face sheet dated 12/20/203 for Resident #56 indicated that she was admitted to the facility on [DATE] with diagnoses of disorder of bone density (weakened bones). Record review of a Comprehensive MDS dated [DATE] for Resident #56 indicated that she had no cognitive impairment with a BIMS score of 15. Record review of a psychiatric note dated 07/05/2023 for Resident #56 indicated that new diagnosis of schizoaffective disorder, bipolar type (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania) was added. Record review of a PASSR Level 1 screening dated 6/13/22 for Resident #56 indicated that she was negative. No new evaluation was done after new diagnoses were added on 7/5/2023. 3. Record review of a facility face sheet dated 12/20/2023 for Resident #67 indicated that she was admitted to the facility on [DATE] with diagnoses of myocardial infarction (heart attack). Record review of a Comprehensive MDS dated [DATE] for Resident #67 indicated that she had no cognitive impairment with a BIMS score of 15. Record review of a psychiatric note dated 4/26/2023 for Resident #67 indicated that new diagnoses of Major Depressive Disorder and Post-traumatic Stress Disorder. Record review of a PASSR Level 1 screening dated 1/6/23 for Resident #67 indicated that she was negative. No new evaluation was done after new diagnoses were added on 4/26/2023. 4. Record review of facility face sheet dated 12/19/2023 revealed Resident #76 was an [AGE] year-old female that admitted to the facility on [DATE] with diagnosis of Parkinson (chronic and progressive movement disorder). Record review of significant change MDS dated [DATE] revealed had an anxiety disorder and hallucination diagnosis, and no referral to local contact agency. Record review of medical diagnosis list revealed Resident #76 was diagnosed with psychotic disorder with hallucinations and delusions on 07/24/2023 by a psychiatrist. The facility did complete a new PASSAR level 1 with new qualifying diagnosis until 12/18/2023. Record review of Resident #76's PASSAR level 1 completed prior to admission on [DATE] was negative. During an interview on 12/19/23 at 03:30 pm, the ADON stated she had been completing PASSAR since July 2021. She stated she was trained on completing PASSAR, but she was not aware that a new level 1 PASSAR had to be completed with new identified qualifying diagnosis. She stated the psychiatrist gave the residents the new diagnosis and she added the new diagnosis but missed the need to for a new level 1 PASSAR and PASSAR evaluation. She stated by not completing PASSAR correctly with new identifying diagnosis could affect resident receiving needed services. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 7 of 21 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 12/20/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 12/19/23 at 4:03 pm, the DON stated that she had trained the ADON on PASSAR submission. She stated when a new qualifying diagnosis was received from a physician, then form 1012 had to be completed and a new level 1 had to be submitted if dementia was not the primary diagnosis. She stated there had not been any formal training and she did not have a system for monitoring that PASSAR was completed accurately. She stated if residents identified with a qualifying diagnosis were not accurately assessed for PASSAR, it could affect residents receiving services. During an interview on 12/20/2023 at 8:45 AM, the DON and MDS Coordinator both said the MDS nurses were responsible for coordinating with PASSR services. They said that the MDS nurses and DON were responsible for entering new diagnosis given by the physicians or from hospital stays. They both said the care plans should be updated to reflect the new diagnosis, submit the form 1012, and follow the steps if a new PL1 was needed. The DON said going forward she would in-service staff, pay more attention to diagnoses, and update the PL1 per protocol. The DON said residents could be at risk of not being able to receive appropriate services for mental illness. During an interview on 12/20/23 at 9:11 am, the Administrator stated the ADON was responsible for making sure residents with new qualifying diagnosis get a new PASSAR completed. She stated the ADON was trained by the DON, and she should have known to complete the paperwork for the residents with new qualifying diagnosis. She stated the risk could be missed services under PASSAR and (he/she) expected that all residents were appropriately assessed for PASSAR prior to and during admission at the facility. She stated they did not have a facility policy for PASSAR and used the guidelines from Health and Human services for completing PASSAR level 1 and referring entities. Record review of document titled Detailed item by item guide for referring entities to complete the PASRR Level 1 screening form dated June 2023. The document did not include information regarding the facility completing a new PASRR level 1 for residents that receive a new qualifying diagnosis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 8 of 21 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 12/20/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 3 residents (Resident #1 and Resident # 24) reviewed for quality of care. The facility failed to ensure Residents #1 and 24's indwelling catheters (drains urine from your bladder into a bag outside your body) had a securement device to anchor their catheters. This failure could place residents at risk for urinary tract infections and catheter related injuries. Findings: 1. Record review of facility face sheet dated 12/21/2023 revealed Resident #1 was a [AGE] year-old female that admitted on [DATE] with diagnosis of chronic kidney disease and urinary tract infection (UTI). Record review of annual MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 12 indicating moderate impairment in thinking. Indwelling catheter was new and was not present at time of MDS. Record review of comprehensive care plan dated 11/20/2023 revealed Resident #1 did not have indwelling catheter at time care plan was updated. Record review of the physician order dated 12/17/2023 revealed Resident #1 may have an indwelling catheter and to record output every shift. There was no order to check for catheter securement device. Record review of nurses note dated 12/17/2023 revealed Resident # 1 returned from the hospital on [DATE] with an indwelling catheter due to a UTI. During an observation and interview on 12/18/23 at 2:00 pm, Resident #1 had an indwelling catheter present in a privacy bag and tubing was not secured with a securement device. Resident # 1 stated she was at the hospital over the weekend, and they put the catheter in because she had an infection. During on observation on 12/19/2023 at 10:48 am, Resident # 1 received catheter care by CNA C and CNA D. Resident # 1 did not have a catheter tubing securement device in place. During an interview on 12/19/2023 at 10:55 am, CNA C stated she was not sure about the securement device, the nurses put those on, but she would find out. During an interview on 12/19/2023 at 10:57 am, Resident #1 stated the catheter was heavy and pulling and was causing discomfort. During an interview on 12/19/23 at 11:02 am, LVN A stated Resident # 1 came back from the hospital with an indwelling catheter and the nurse was responsible for checking the catheter every shift to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 9 of 21 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 12/20/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some ensure it was patent (unobstructed) and a securement device should have been in place to prevent discomfort from pulling and irritation. She stated she would reassess Resident #1 to ensure a securement device was in place. During an interview on 12/20/23 at 09:16 am LVN B stated she was responsible for catheter assessments, and she assessed Resident #1 the morning of 12/18/2023 and there was a securement device in place. She stated Resident #24 did not have a securement device and she missed that she did not have one. She stated there was no specific order for checking for the securement device, she just checked the catheter for patency. She stated by not having a securement device for the catheter tubing it could cause pulling, irritation, discomfort, infections, and dislodgement. 2. Record review of an admission Record dated 12/20/2023 for Resident #24 indicated he admitted to the facility on [DATE] and was [AGE] years old with a diagnosis of hypothyroidism (thyroid gland does not produce enough thyroid hormone), type 2 diabetes, dementia (a progressive or persistent loss of thinking) and hypertension (high blood pressure). Record review of a Significant Change MDS assessment for Resident #24 dated 10/27/2023 indicated he was unable to complete the interview with a BIMS score of 99 and he had an indwelling catheter. Record review of a care plan undated for Resident #24 indicated he had an indwelling catheter with foley care to be provided every shift and prn. Interventions to ensure tubing was anchored to the resident's leg or linens so that tubing is not pulling on the urethra. Record review of active physician orders for Resident #24 indicated an order to change foley catheter stabilization device in place every 7 days with a start date of 12/20/2023. Record review of a Treatment Administration Record (TAR) for Resident #24 for 12/1/2023 to 12/31/2023 indicated a treatment order for foley catheter care every shift and as prn was completed daily as indicated by checkmarks and staff member's initials from December 1, 2023 to December 20, 2023. During an observation on 12/19/2023 at 9:52 AM, CNA J and CNA E were in the room of Resident #24 to provide incontinent and foley catheter care. Resident #24 had an indwelling catheter in place that was not anchored to his thigh using a tubing securement device. During an observation and interview on 12/19/2023 at 3:55 PM, CNA E was in the room of Resident #24. The Surveyor questioned CNA E if Resident #24 had a tubing securement device for his indwelling catheter and she pulled down the linens to look at his foley catheter. Resident #24's indwelling catheter was not secured and was positioned on the left side of bed with privacy bag noted. CNA E said the nurses were responsible for ensuring the foley catheters were anchored. During an interview on 12/19/2023 at 4:05 PM, LVN F said she had been employed at the facility for 2 years on the 6a-6p shift. She said the nursing staff alternated halls daily and today 12/19/2023 she was assigned to the hall for Resident #24. She said Resident #24 was the only resident on hall 100 that had a foley catheter. She said normally residents with foley catheters should have them anchored to the resident's thigh. She said it was not listed on the TAR for the foley catheters to be anchored and it only indicated for foley catheter once per shift. She said they normally placed anchors for the catheters but did not know if they were out of them at the facility. She said residents could get a tear especially for men if the catheters were not anchored. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 10 of 21 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 12/20/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm During an interview on 12/20/23 at 09:05 am, the DON stated LVN B was responsible for assessing residents with indwelling catheters to ensure there was a securement device in place. She stated the charge nurse should also assessed the securement device on each shift to ensure the resident was not having any discomfort or pulling of the tubing. She stated she expected every resident with an indwelling catheter to have a securement device. Residents Affected - Some During an interview on 12/20/23 at 09:09 am, the Administrator stated the nursing staff were responsible for ensuring catheters were secured and in place. She stated by not having a device it could cause discomfort, infections, and dislodgement. She stated she expected each resident with a catheter to have a securement device. Record review of facility policy titled Catheter Care, Urinary dated August 2022 indicated, .ensure that the catheter remains secured with a securement device to reduce friction and movement at the insertion site . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 11 of 21 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 12/20/2023 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 0760 Ensure that residents are free from significant medication errors. 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 were free from significant medication errors for 1 of 8 residents (Resident #45) reviewed for pharmacy services. Residents Affected - Few The facility failed to ensure MA P held Resident #45's Losartan Potassium 25mg (for high blood pressure) for a blood pressure reading that was lower than ordered parameters. This failure could place residents at risk for inaccurate drug administration resulting in decline in health and decreased quality of life. Findings included: Record review of a facility face sheet dated 12/19/2023 for Resident #45 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of atrioventricular block (when the electrical signal that controls your heartbeat is partially or completely blocked) and hypertension (high blood pressure). Record review of a Comprehensive MDS assessment dated [DATE] for Resident #45 indicated she had moderate cognitive impairment with a BIMS score of 11. Record review of a care plan for Resident #45 dated 10/18/2023 indicated she had hypertension with interventions to administer medications as ordered, and monitor/document for side effects and effectiveness. Record review of an active physician order summary report dated 10/17/2023 for Resident #45 indicated she had the following medication orders with a start date of 01/06/2023: Losartan Potassium Tablet 25 MG Give 1 tablet by mouth one time a day related to Essential (primary) hypertension; hold if systolic blood pressure is less than 110 or diastolic blood pressure is less than 60; and Carvedilol Tablet 6.25 MG Give 1 tablet by mouth two times a day related to essential (primary) hypertension; hold if systolic blood pressure is less than 110 or diastolic blood pressure is less than 60. Record review of the Medication Administration Records for Resident #45 for the months of October and November 2023 indicated that resident had received: Losartan 25 mg by mouth on 10/26/2023 when her blood pressure reading was 109/60 Losartan 25 mg by mouth on 11/17/2023 when her blood pressure reading was 106/72 Carvedilol 6.25 mg by mouth on 10/26/2023 when her blood pressure reading was 109/60, and Carvedilol 6.25 mg by mouth on 10/26/2023 when her blood pressure reading was 108/62. During an observation on 12/19/2023 at 8:20 AM, MA P administered medications to Resident #45. Prior to administering medications to Resident #45, she checked her blood pressure which was outside parameters at 107/61. She continued and administered Losartan 25 mg by mouth. During an interview on 12/19/2023 at 3:25 PM, MA P said she had been a medication aide for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 12 of 21 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 12/20/2023 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few approximately 15 years. She said the parameters for Resident #45's Losartan were to hold if less than 110/60. She then looked at Resident #45's blood pressure reading from earlier that morning and said It was 107/71, I should have held it. She said residents' blood pressure could bottom out if they get a blood pressure medication when they are below parameters. During an interview on 12/19/23 at 3:30 pm, the DON said that the risks to residents that get blood pressure medications when they are below parameters include blood pressure plummeting. She said that parameters for almost all other residents are 100/60, but she would be clarifying to ensure if there was a reason for Resident #45's to be higher. She said that she expected her staff to pay better attention because parameters may be personalized to residents. During an interview on 12/20/2023 at 2:30 pm, Administrator said that going forward, she would have the nurse clarifying the orders for Resident #45. She said that her parameters were 110/60 and everyone else in the building was 100/60. She was unsure at this time whether there was a reason for hers being higher, but they would be clarifying it. She said that a resident that gets a blood pressure medication when their blood pressure is below parameters could be at risk of their blood pressure bottoming out. During an interview on 12/20/2023 at 2:45 pm, MD said that he could not think of any harm unless they had been significantly below parameters. He said that he would consult with his nurse practitioner to see if there was a reason for the higher parameters and change them if needed. Record review of the facility's policy titled Administering Medications dated 2001, with revision date of April 2019 read .Medication are administered in accordance with prescriber orders . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 13 of 21 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 12/20/2023 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 maintain and ensure safe and sanitary storage of residents' food items, per facility policy, for 2 of 7 resident's (Resident #21 and 38) personal refrigerators reviewed for food and nutrition services. Residents Affected - Few The facility failed to ensure the refrigerator for Resident #21 did not contain strawberry and chocolate boostdated 11/5/2023 and 12/5/2023 and a plastic container with something orange that was undated. The facility failed to ensure the refrigerator for Resident #38 did not contain chocolate boost and a bowl of pot pie that was undated. These failures could place residents at risk for food borne illnesses. Findings include: Record review of a facility policy titled Personal Property undated indicated, .Residents are permitted to bring personal property and use personal possession to create a home-like environment. 3b. Personal refrigerators. v. Staff must discard food from refrigerators that show obvious signs of potential foodborne danger, and/or is beyond expiration date . Record review of a facility policy titled Foods Brought by Family/Visitors with a revised dated March 2022 indicated, .Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. 6. The nursing staff will discard perishable foods on or before the use by date . 1. Record review of an admission Record dated 12/20/2023 for Resident #21 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia (progressive or persistent loss of thinking), parkinsonism (characterized by tremor, slow movements and stiffness), anemia (a problem of not having enough healthy red blood cells to carry oxygen to the body's tissues), and major depressive disorder (persistent feeling of sadness and loss of interest). Record review of a Quarterly MDS Assessment for Resident #21 dated 9/13/2023 indicated she had moderate impairment in thinking with a BIMS score of 9. She required supervision with eating and the assistance of setup help only. Record review of a care plan for Resident #21 dated 5/20/2022 indicated she had a personal refrigerator in room. Interventions included for housekeeping to check it weekly for outdated food and discard. Record review of an active physician order for Resident #21 dated 5/20/2022 indicated an order for a personal refrigerator. During an observation on 12/18/2023 at 9:52 AM, Resident #21's personal refrigerator had two bottles of strawberry boost dated 11/5/23 and two bottles of chocolate boost dated 12/5/23 and a plastic container with something orange that was undated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 14 of 21 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 12/20/2023 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 2. Record review of an admission Record for Resident #38 dated 12/20/2023 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of postherpetic polyneuropathy (pain that persists after having shingles), Alzheimer's disease (a progressive disease that destroys memory), dementia, and age-related osteoporosis (brittle, bone disease). Record review of a Quarterly MDS assessment dated [DATE] for Resident #21 indicated she did not have any impairment in thinking with a BIMS score of 13. She required set up or clean up assistance with eating. Record review of a care plan for Resident #38 dated 5/19/2022 indicated she had a personal refrigerator in room. Interventions included for housekeeping will check weekly for outdated foods and discard. Record review of an active physician order for Resident #38 dated 5/19/2022 indicated an order for a refrigerator in room. During an observation on 12/18/2023 at 9:52 AM in Resident #38's personal refrigerator had two bottles of strawberry boost dated 11/5/23 strawberry boost, two bottles of chocolate boost dated 12/5/23, and plastic container with something orange that was undated. During an observation and interview on 12/18/2023 at 2:45 PM, HSK K was on hall 100 and said she had only been employed at the facility for 6 days. She said the housekeeping staff were assigned a hall each day. She said housekeeping was responsible for checking the personal refrigerators on Fridays. She said they checked the personal refrigerators for temperatures, ice buildup in the freezers, and for any expired foods or drinks. She said today was her first day to work on hall 100. During an observation on 12/18/2023 at 2:48, Resident #21's personal refrigerator was cleaned and did not have any expired items or undated food items. During an observation on 12/18/2023 at 2:49 PM, Resident #38's personal refrigerator was cleaned and did not have any expired items and undated food items. During an interview on 12/18/2023 at 3:00 PM, HSK L said the housekeeping staff were responsible for checking the personal refrigerators once a week on Fridays. She said housekeeping staff could check more often if they needed to. She said they were supposed to check the personal refrigerators every other day for items like milk with expiration dates. She said they kept a log on their cleaning carts with the temperature readings and cleaning of the refrigerators on Fridays. She said she last worked on hall 100 on Sunday 12/17/2023. She said residents could get sick if they ate foods that were expired. She said she did not know that Residents #21 and #38 had expired items in their personal refrigerators. Record review of a facility refrigerator log for hall 100 undated indicated room [ROOM NUMBER] for Resident #21 was not initialed to indicate it was checked. room [ROOM NUMBER] for Resident #38 was blank with no initials. During an interview on 12/20/2023 at 2:19 PM, the Administrator said the housekeepers were responsible for checking the personal refrigerators. She said the housekeepers had a log and they checked the refrigerators every Friday for temperatures and if a resident allowed them to discard any food items that were not safe. She said if a resident refused to allow the housekeepers to discard items, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 15 of 21 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 12/20/2023 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 then it should be care planned. She said residents could get sick if they ate or drank items that were expired. She said going forward, she would change the cleaning dates and educate the housekeeping supervisor and would oversee to ensure it was done or designate someone. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 16 of 21 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 12/20/2023 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 observations, interviews, and record reviews, the facility failed to establish and 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 8 staff (CNA G, CNA Q, CNA N) and for 2 of 5 residents reviewed for infection control (Resident #9 and Resident #45). Residents Affected - Some 1. The facility failed to ensure MA P wore gloves when administering eye drops to Resident #45. 2. The facility failed to ensure the Treatment nurse used a clean gauze pad to dry a wound for Resident #9. 3. The facility failed to ensure CNA G, CNA Q, and CNA N washed or sanitized their hands when passing out meal trays to residents on Hall 200 and Hall 300. These failures could place residents at risk of exposure to communicable diseases and infections. Findings included: 1.Record review of a facility face sheet for Resident #9 dated 12/20/2023 indicated that she admitted to the facility on [DATE] with diagnosis of complication of nephrostomy catheter (tube draining fluid from kidneys). Record review of a Comprehensive MDS dated [DATE] for Resident #9 indicated that she had no cognitive impairment with a BIMS score of 15. Bowel and Bladder section of MDS was answered yes for indwelling catheter (including suprapubic catheter and nephrostomy tube). Record review of a physician order report dated 12/20/2023 for Resident #9 indicated that she had a physician's order stating: Clean around Nephrostomy catheters to lower back with SNS,(sterile normal saline), pat dry then leave open to air. May apply a dry dressing qd (every day) if sites have any drainage with order start date of 1/13/2023. Record review of a Care Plan for Resident #9 dated 10/12/2023 indicated that Resident #9 had a surgical site to both right and left flank where Nephrostomy tubes exit, with interventions to monitor sites for signs and symptoms of infection and report to MD. During an observation and interview on 12/19/2023 at 3:55 pm, the Treatment Nurse was observed performing wound care to Resident #9's nephrostomy tubes. She washed her hands before beginning treatment. She placed a plastic trash bag on the bed next to resident to discard supplies in while performing care. When she was finishing wound care, she dropped a clean 4x4 gauze pad into the trash bag. She reached to grab it back out of the bag, hesitated, then continued to pick it up and patted the wound dry with it. During an interview on 12/19/2023 at 4:15 pm, the Treatment Nurse said that she should not have picked the gauze up out of the trash to pat the clean wound dry with. She said that this could be an infection risk to the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 17 of 21 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 12/20/2023 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 2.Record review of a facility face sheet dated 12/19/2023 for Resident #45 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of atrioventricular block (when the electrical signal that controls your heartbeat is partially or completely blocked) and hypertension (high blood pressure). Record review of a Comprehensive MDS assessment dated [DATE] for Resident #45 indicated she had moderate impairment in thinking with a BIMS score of 11. During an observation on 12/19/2023 at 8:20 am MA P was observed administering eye drops to Resident #45. She did not wear gloves during administration. During observation of meal service on 12/18/2023 at 11:45 AM, CNA Q took meal tray into room [ROOM NUMBER] and repositioned resident to sitting position on side of bed and moved bedside table in position with tray on top of table. CNA M did not wash or sanitize hands prior to exiting room or handling meal tray for next room, 306. CNA did not sanitize hands prior to passing tray to room [ROOM NUMBER] or after setting up tray on bedside table. During observation of meal service on 12/19/2023 at 12:30 PM, CNA G and CNA N were passing trays on hall 200. CNA G entered rooms [ROOM NUMBER] and was touching bedside tables while setting up meals. CNA G did not wash or sanitize hands upon exiting rooms or prior to serving trays from the cart in the hallway. CNA N was passing a tray to room [ROOM NUMBER] and did not wash or sanitize hands before or after serving and setting up tray. During an interview on 12/18/2023 at 12:23 PM with CNA Q said the staff were to use hand sanitizer before getting the tray and after serving. She stated she had hand sanitizer in her pocket but just did not use it. CNA A stated that germs could be passed to other residents if their hands were not sanitized during meal service. During an interview on 12/20/2023 at 10:30 am MA P said that she did not wear gloves when administering the eye drops. She said that she had been nervous, but that she should have worn gloves to prevent infection. During an interview on 12/20/23 at 01:40 PM, the Administrator said the staff were expected to wash or sanitize their hands if an object that was touched by the resident was touched by the staff while passing trays, and they should be sanitizing or washing their hands when they exited the room or were picking up the next tray. Administrator stated that the expectation for the staff ws to follow the policy and to sanitize their hands after any contact with the residents or anything touched by the resident. During an interview on 12/20/2023 at 01:54 PM, the DON stated that staff were expected to sanitize their hands between each tray and if their hands were visibly soiled. The DON stated they were expected to wash their hands with soap and water. DON stated that she expected the staff to follow hand washing and hand sanitizing policy while performing all duties. DON stated that she would be doing additional training and observations with staff. During an interview on 12/20/2023 at 2:30 pm Administrator said that the facility would be implementing education regarding proper procedures. She said that there was a new treatment nurse, and she would also be receiving more education regarding proper procedures. She said that they may shadow her for a while to ensure proper technique was followed. She said that residents were at risk of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 18 of 21 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 12/20/2023 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 developing infection if proper wound care techniques are not followed. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/20/2023 at 2:50 pm DON said that she expected her staff to follow policy when passing medications, which included wearing gloves when administering eye drops. She said that residents could be at risk of developing an eye infection if staff did not wear gloves. Residents Affected - Some Record review of a facility policy titled Nephrostomy tube, long term care of dated 1/12/2023 read .After cleaning, dry each area with a fresh 4 x 4 gauze . Record review of facility policy titled Instillation of Eye Drops dated January 2014 read .Steps in the Procedure .2. Wash and dry your hands thoroughly, 3. Put on gloves . Record review of a facility policy titled Handwashing/Hand Hygiene with a revised date of August 2019 indicated .This facility considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 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; l. After contact with objects (e.g., medical equipment) in immediate vicinity of the resident; p. Before and after assisting a resident with meals. Record Review of nurse aide proficiency indicated that Handwashing procedural guideline demonstration was completed correctly for CNA G on 7/7/2023, CNA N on 2/9/2023 and CNA Q on 2/9/2023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 19 of 21 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 12/20/2023 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 residents could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside; and toilet and bathing facilities for 1 of 7 residents (Resident #51) reviewed for call lights. Residents Affected - Few The facility failed to ensure Residents #51's emergency call light located in the bathroom would reach the floor. This failure could affect residents who used their call light or desired to use the call light and place them at risk of not being able to notify staff of their needs. Findings: Record review of facility face sheet dated 12/19/2023 indicated Resident #51 was an [AGE] year-old female admitted to the facility on [DATE] with diagnosis of arthropathy (arthritis). Record review of comprehensive MDS assessment dated [DATE] indicated Resident #51 had a BIMS score of 06 indicating severely impaired cognition. Resident #51 required substantial/maximal assistance with toileting. Record review of Resident #51's comprehensive care plan dated 10/10/2023 indicated Resident #51 was at risk for falls related to history of falls, decreased balance, and increased weakness. Interventions included: .The resident needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light . During an observation on 12/18/23 at 09:20 am, the string on Resident #51's bathroom call light was observed to be too short, was approximately four inches long and would not have been reachable from the floor in the event of a fall. During an interview and observation on 12/19/2023 at 10:20 am, Resident #51 was observed sitting in her room in wheelchair with family in the room getting ready to go out for lunch. She said that she used the restroom by herself, but she did not remember ever needing to use the call light in the restroom. A family member, in room at the time, said that Resident #51 did use the restroom alone even though they encouraged her to call for help. During an interview on 12/19/2023 at 11:00 am, the Administrator said that they would be making rounds to ensure no other call lights were inaccessible. She said that Resident #51's light had been fixed and she was unsure how it had gotten missed. She said that all residents should be able to reach the call light in case of a fall in the bathroom. During an interview on 12/20/2023 at 2:30 pm, the DON said that residents could be at risk of not being able to reach the call light if they were to fall in the bathroom and the call light was too short. Review of a facility's policy titled Call System, Residents dated September 2022 read .Each (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 20 of 21 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 12/20/2023 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 0919 resident is provided with a means to call staff directly for assistance from his/her bed, from Level of Harm - Minimal harm or potential for actual harm toileting/bathing facilities and from the floor Review of a facility's policy titled Answering the Call Light dated September 2022 read Residents Affected - Few .Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676344 If continuation sheet Page 21 of 21