Inspection·September 8, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some had been made for a future shift). Observation of the number of cards in the cart on 09/03/23 at 10:25 a.m. showed 16 cards in the cart. During an interview on 09/03/23 at 10:21 a.m. LVN C said she works the 100-hall. LVN C said she completed a narcotic count this morning with the 10:00 a.m. to 6:00 a.m. Nurse. LVN-C said she not only counts the sheets but counts each pill on each card. LVN C said the count this morning showed 16 cards and all pills were accounted for in the cart. LVN C said there were two cards that went from the nurse's cart to the medication cart because the medication was changed to a routine medication and not a PRN (As needed) medication. LVN C said when the medication was changed to the medication aide cart, whomever moved the medication wrote a minus 2 on the narcotic count sheet showing the two cards had been removed. During an interview on 09/03/23 at 10:47 a.m. LVN/ADON said she did not remove the narcotics from the nursing cart on 100-hall to the medication cart on 100-hall. LVN/ADON said more in-service was needed on facility procedures for handling narcotics including transferring narcotics from one cart to the other. LVN/ADON the training needed to include discontinued medication and documentation of narcotics. LVN/ADON said each pill is counted during the narcotic count at the end of each shift or when the keys to the cart are given to another nurse or medication aide. LVN/ADON said the count sheet is used to document the count had been completed before the keys were passed as well as the number of count sheets on the cart at the time of the count. LVN/ADON said there had been a problem with missing count sheets and that is why the number of count sheets are also counted during the narcotic count. LVN/ADON said the nurses/medication aides are to count each pill on each card and count the number of count sheets on the cart to ensure none of the narcotic are missing. LVN/DON said staff failed to accurately document the count had been performed. Cart 2: Review of a narcotic count sheet dated September 2023 for the Medication Aide cart for the 100-hall showed: On 09/01/23 at the end of the 6:00 a.m. to 2:00 p.m. shift there were a total of 21 cards which indicated the number of controlled drugs in the cart. On 09/01/23 during the 2:00 p.m. to 10:00 p.m. shift there were 21 cards. On 09/01/23 the count for the 10:00 p.m. to 6:00 a.m. shift there were 24 cards. (The 24 had been written over what appeared to be 22) There was no documentation of why the increase from 21 cards to 24 cards. On 09/02/23 during the 6:00 a.m. to 2:00 p.m. the number of cards was left blank. On the 2:00 p.m. to 10:00 p.m. the number of cards showed 20. There was no documentation as to why the number of cards changed from 24 to 20. On the 10:00 p.m. to 6:00 a.m. shift there was 19. There was no documentation as to why the number of cards changed from 20 to 19. On 09/03/23 during the 6:00 a.m. to 2:00 p.m. shift the number of cards was blank. An observation and record review on 09/03/23 at 10:26 a.m. of the medication aide cart for the 100-hall showed an entry for 09/03/23 for the 10:00 p.m. to 6:00 a.m. showing 19 cards. (The entry had been made for a future shift). Observation of the number of cards in the card on 09/03/23 at 10:28 a.m. showed 19 cards in the cart. During an interview on 09/03/23 at 10:21 a.m. LVN C said during med count she would count all the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675774 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675774 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Healthcare and Rehabilitation - Greenville 2300 Jack Finney Blvd Greenville, TX 75402 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 0755 Level of Harm - Minimal harm or potential for actual harm pills and the cards. LVN C said she was to also count the number of sheets to ensure none of the count sheets are missing and record the number of sheets on the count sheet when she completes the count. LVN C only the DON or the ADON are to remove narcotics or count sheets from the cart. Cart #3: Residents Affected - Some Observation on 09/03/23 at 10:35 a.m. showed the cart was on the 300-hall in front of room [ROOM NUMBER]. The door to room [ROOM NUMBER] was closed. The outside lock to the cart was unlocked. MA A was observed exiting the room. During an interview on 09/03/23 at 10:35 a.m. MA A said she was the medication aide for the 300-hall. MA A said she was in room [ROOM NUMBER] taking the blood pressure of the resident before administering his medication. MA A said she left the cart unlocked and should have locked the cart before going into the resident's room to take his blood pressure. MA said she conducted a count with LVN A at the 6:00 a.m. when she started her shift. MA A said she did not sign the count sheet showing the count had been completed. MA A said there is only one card of narcotics in the 310-317 cart. During an interview on 09/03/23 at 10:35 a.m. LVN A said he is the charge nurse for the 300-hall. LVN A said he counted the cart with MA A this morning at the start of her shift. LVN A said he failed to document the count was completed. LVN said all narcotics should be counted before the keys are given to another staff. LVN said there is only one card of narcotics in the 310-317 cart. Review of a narcotic count sheet dated September 2023 for the Medication Aide cart for the 310-317 hall showed: On 09/01/23 at the end of the 6:00 a.m. to 2:00 p.m. shift there was a total of 1 card which indicated the number of controlled drugs in the cart. On 09/01/23 during the 2:00 p.m. to 10:00 p.m. shift there was 1 card. On 09/01/23 the count for the 10:00 p.m. to 6:00 a.m. shift there was 1 card. On 09/02/23 during the 6:00 a.m. to 2:00 p.m. there was 1 card. On the 2:00 p.m. to 10:00 p.m. the number of cards showed 1. On the 10:00 p.m. to 6:00 a.m. shift the number of cards was left blank. On 09/03/23 during the 6:00 a.m. to 2:00 p.m. shift the number of cards was blank. Cart #4: Review of a narcotic count sheet dated September 2023 for the Medication Aide cart for the 200-hall showed: On 09/01/23 at the end of the 6:00 a.m. to 2:00 p.m. shift there were a total of 33 cards which indicated the number of controlled drugs in the cart. On 09/01/23 during the 2:00 p.m. to 10:00 p.m. shift the signatures were left blank and the count was 33. On 09/01/23 the count for the 10:00 p.m. to 6:00 a.m. shift there were 33 cards. On 09/02/23 during the 6:00 a.m. to 2:00 p.m. the number of cards was 33. On the 2:00 p.m. to 10:00 p.m. the number of cards showed 33. On the 10:00 p.m. to 6:00 a.m. shift there were 33. On 09/03/23 during the 6:00 a.m. to 2:00 p.m. shift the number of cards was blank. There was an entry of 33 cards for the 10:00 p.m. to 6:00 a.m. shift. (The entry had been made for a future shift). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675774 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675774 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Healthcare and Rehabilitation - Greenville 2300 Jack Finney Blvd Greenville, TX 75402 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 0755 An Observation of the number of cards in the cart on 09/03/23 at 12:20 p.m. showed 33 cards in the cart. Level of Harm - Minimal harm or potential for actual harm During an interview on 09/03/23 at 12:20 p.m., LVN B said she was the charge nurse for the 200-hall. LVN B said she did the narcotics count with the nurse going off shift when she started this morning at 6:00 a.m. LVN B said she failed to enter the number of cards on the count sheet after completing the count. LVN B said she was not sure why the nurse signed showing the count was 33 on the upcoming night shift, but more than likely it was done in error. Residents Affected - Some During an interview on 09/08/23 at 9:10 a.m., the DON said she just started as the DON this week. The DON said she is concerned with the security of the narcotics and had updated the narcotics log and provided training to all nursing staff on conducting a narcotic count, documentation of when narcotics are received, administered, or discontinued. The DON said she also provided training to nurses on what to do when residents are discharged home or go out on leave. The DON sad she and the ADON are responsible for monitoring the carts to ensure nursing staff are accounting for all narcotics each shift. The DON said two nurses are required to sign when a narcotic is delivered, when the narcotic is placed on the medication cart, and when the narcotic is removed. The DON said this information will be recorded and reconciled with the count sheet during the narcotic count each shift and any variation in the count will immediately reported to the DON or the ADON. During an interview on 09/08/23 at 11:00 a.m. the Administrator said the concerns of the narcotic count was identified at the beginning of August 2023 when some medications were found to be missing. ADM said it was addressed in the QAPI meeting on July 31, 2023. ADM said the new DON had implanted a new count sheet that required two nurses to sign any time a narcotic was delivered or removed from the medication carts. ADM said the DON and/or the ADON will monitor to ensure narcotics are accounted for and kept secure. Review of in-service records dated 09/03/23 showed nursing staff received training on Discharging a resident with medication, Residents discharging to the hospital, Discrepancies in narcotic count, and Narcotic count. Review of in-service records dated 06/30/23 showed Discharging Home and Narcotics .Narcotic count sheet signed by 2 nurses the total medication sent with resident upon discharge. Resident/family must sign to verify medications released to them. Review of Quality Assurance and Performance Improvement (QAPI) dated 07/31/23 showed the issue of narcotics count and security was addressed at the meeting. The Medical Director was not present at the meeting. Review of the facility policy for Controlled Medication-Storage and reconciliation dated 01/2022 showed It is the policy of this facility to safeguard access and storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse using separately locked, permanently affixed compartments .This facility will maintain a process for monitoring, administration, documentation, reconciliation and destruction of controlled substances. 8. A reconciliation or physical inventory of all controlled medications is conducted by two licensed nurses and is documented on an audit record at each shift change. Alternatively, the shift change audit may be recorded on the accountability record if there is a designated column for the audit. ? The reconciliation at shift change includes controlled medications stored under refrigeration and those stored in emergency kits . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675774 If continuation sheet Page 4 of 4