Health inspection·July 31, 2024

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System for 1 of 6 residents (Resident #33) reviewed for MDS accuracy and completion. Residents Affected - Some Resident #33's Discharge MDS assessment dated [DATE] was not transmitted within 14 days of completion to CMS. This deficient practice could result in MDS inaccuracies. The findings were: Record review of a closed record revealed a Discharge MDS Assessment Return Anticipated dated 4/11/2024 was completed on 4/18/2024 and accepted, but not transmitted as of 7/30/2024. Record review of a MDS Final Validation Report dated 7/30/2024 indicated Resident #33 had an assessment with a target date of 4/11/2024 that was accepted and indicated the record was submitted late and the submission was more than 14 days. During an interview on 7/30/2024 at 11:46 AM, the MDS Coordinator said she had been employed at the facility since March 2024. She said there were two MDS Coordinators and she was responsible for completing the assessments with the last names of A-K. She said she completed the discharge assessment dated [DATE] for Resident #33. She said the MDS assessment was not transmitted, and she had reopened, corrected, and transmitted the assessment. She said there was a risk for PBJ information to be inaccurate and it could show that the resident was still in the facility and not discharged along with an inaccurate census for the facility. She said the assessment should have been transmitted by 4/25/2024. During an interview on 7/31/2024 at 10:10 AM, the DON said she had been employed at the facility since February 2023. She said the MDS Coordinators were responsible for completing and transmitting the MDS assessments and all she did was sign them . During an interview on 7/31/2024 at 10:30 AM, the VP of Clinical Reimbursement said the facility should be following the RAI manual for completion and transmission of MDS assessments. She said the assessments should be transmitted within 14 days after the assessment had been closed. She said the MDS Coordinators should be reviewing the validation report to see if there were any problems that needed to be corrected. She said when the MDS was submitted the validation report would let them know if the assessment was accepted or not. She said if assessments were not transmitted to CMS, it could Page 1 of 18 675998 675998 07/31/2024 Legacy at Town Creek 2212 W Reagan St Palestine, TX 75801

F 0640 Level of Harm - Potential for minimal harm Residents Affected - Some throw off the census numbers and CMS would not be able to recognize that the resident had been discharged . During an interview on 7/31/2024 at 11:00 AM, the Administrator said the MDS assessments should be transmitted within 7 days of completion. She said the MDS Coordinators should be looking at the validation report once completed. She said on yesterday 7/30/2024 the MDS Coordinator corrected and transmitted the discharge assessment for Resident #33. She said there was a risk for facility's data not being accurate if assessments were not transmitted timely. She said the facility did not have a policy on transmitting MDS assessments and they followed the RAI manual. 675998 Page 2 of 18 675998 07/31/2024 Legacy at Town Creek 2212 W Reagan St Palestine, TX 75801

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 1 of 1 facility reviewed for accident hazards. The facility failed to develop and implement a policy and procedure to properly handle the care of Hoyer lift slings including interventions to inspect the Hoyer sling for signs of damage before each use and not removing damaged slings from service. This deficient practice could result in falls and injuries if damaged lift sling broke during mechanical lift transfers. The findings were: 1. Record review of a facility face sheet dated 07/30/2024 indicated Resident #43 was a [AGE] year-old female that admitted to the facility on [DATE] with diagnoses of muscle weakness, diabetes (high glucose level in the blood), and essential (primary) hypertension (high blood pressure). Record review of a comprehensive care plan revised 06/17/2024 indicated Resident #43 was a lift transfer for all transfers. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #43 had a BIMS score of 7 indicating severe impaired cognition, impairment of both lower extremities, and dependent for all transfers. 2. Record review of a facility face sheet dated 07/30/2024 indicated Resident #36 was a [AGE] year-old female that admitted to the facility on [DATE] with diagnoses of history of breast cancer and essential (primary) hypertension (high blood pressure). Record review of a comprehensive care plan revised 06/06/2024 indicated Resident #36 was a mechanical lift transfer for all transfers. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #36 had a BIMS score of 14 indicating intact cognition, impairment of both lower extremities, and dependent for all transfers. During an observation on 07/29/2024 at 10:11 AM, Resident #43 sitting in a wheelchair with a lift sling underneath her buttocks, the straps were faded in color, the blue strap was almost gray in color, the care tags were illegible, torn, crinkled, and [NAME]. During an observation and interview on 07/30/2024 at 10:40 AM Resident #43 was in bed sleeping. A lift sling was lying on Resident #43's wheelchair. The Hoyer sling straps were light in color almost gray, the tag was illegible, torn, and shredded. CNA A said he worked when needed, he was agency staff. CNA A said he would take any Hoyer sling out of service that had tears or fraying and does not know how long they stay in service before they were removed. CNA A was not aware the manufacturer recommended for them to be taken out of service if the sling had a change in color or the label was illegible, that it indicated it had been worn, bleached, or was compromised. He said he would remove 675998 Page 3 of 18 675998 07/31/2024 Legacy at Town Creek 2212 W Reagan St Palestine, TX 75801

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the sling being used for Resident #43 because it was unsafe. CNA A said he had several residents that required a Hoyer lift for transfers. CNA A said that if a sling was not available on the hallway he would go to the linen closet and retrieve one for use. CNA A said the resident could suffer an injury or could be scared to get up with a lift if they were dropped. During an observation and interview on 07/30/24 at 11:15 AM of the laundry area revealed there were 4 Hoyer slings hanging to dry. Laundry Staff B worked at the facility for 2 years and Laundry Staff C worked here for 16 years and said she had received training to air dry the Hoyer slings, remove slings that have ravels on the edges, and threads that were pulling out. Laundry Staff B and Laundry staff C were not aware the manufacturer recommended for the Hoyer slings to be taken out of service if the sling had a change in color or the label was illegible, that it indicated it had been worn, bleached, or was compromised. During an observation and interview on 07/30/24 at 11:35 AM Resident #36 had a Hoyer sling sitting on her wheelchair, straps were faded light in color, the tag was crinkled. Resident #36 said the sling was provided by her hospice service and she had no issues with the staff using it for her transfers. During an interview on 07/30/24 at 11:45 AM the Hospice Nurse said the sling was provided by the hospice company for Resident #36. She said she was not aware that the slings were to be removed from service if they were faded or the tags were illegible. The Hospice Nurse called the Hospice durable medical equipment representative for a replacement sling and to initiate inspection of all slings provided to the facility. During an interview with the DON on 07/30/2024 at 12:15 PM, the DON said she worked for the facility for almost 6 months. She said she removed slings if they have holes, frays, or strings but she was not aware the manufacturer recommended for them to be taken out of service if the sling had a change in color or the label was illegible, that it indicated it had been worn, bleached, or was compromised. The DON said the resident could suffer an injury if the straps broke and it was all the staff's responsibility to remove defective slings from service. During an interview on 07/31/2024 at 9:30 AM, the Administrator said she was aware the slings required special care, the facility needed to follow manufacturers suggested guidelines. She said if the sling broke it could cause injury to the resident being transferred . A record review of Full Body Slings- Medline, Instructions for use www.medline.com accessed 07/23/2024 reflected .Always inspect slings prior to each use. Signs of rips, tears, or frays indicate sling wear which is unsafe and could result in injury. Signs of color fading, bleached areas, or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury. Any slings with signs of wear or improper laundering should be immediately removed from use Sling maintenance best practices .Check condition before each use. If there is any fraying or visible wear and tear, do not use. Reusable slings should be replaced every six months. Follow care instructions on wash tag. If illegible, do not use. Keep at least two reusable slings per patient on hand-one available and one in the laundry. A record review of a facility policy for Safe Resident Handling/Transfers dated 06/03/2024 indicated .It is the policy of this facility to ensure that residents are handled and transferred safely to 675998 Page 4 of 18 675998 07/31/2024 Legacy at Town Creek 2212 W Reagan St Palestine, TX 75801

F 0689 Level of Harm - Minimal harm or potential for actual harm prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with the current standards and guidelines .16. Slings will be laundered according to manufacturer's instructions and any damaged, broken, or unsafe slings will be removed from service and replaced. Residents Affected - Few 675998 Page 5 of 18 675998 07/31/2024 Legacy at Town Creek 2212 W Reagan St Palestine, TX 75801

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of medications for 2 of 24 residents (Resident #81, and Resident #68) and 2 of 5 medication rooms (Medication room [ROOM NUMBER] and #2) reviewed for medication administration. The facility failed to dispose of expired medications from Medication Rooms #1 and #2 on 7/29/2024 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. Record review of an admission Record for Resident #81 dated 7/30/2024 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia, anxiety disorder (disorder involves persistent and excessive worry that interferes with daily activities), depression (feeling of sadness or loss of interest), and hypertension. Record review of a Quarterly MDS Assessment for Resident #81 dated 5/7/2024 indicated she had severe impairment in thinking with a BIMS score of 2. Special Treatments, Procedures, and Programs indicated she received hospice care while a resident. Record review of a care plan for Resident #81 revised on 1/23/2023 indicated she had impaired cognitive function/dementia or impaired thought processes with interventions to administered medications as ordered. Monitor/document for side effects and effectiveness. Record review of active physician orders for Resident #81 dated 7/30/2024 indicated an order for scopolamine stick 0.2% apply behind ear topically every 6 hours as needed for secretions, apply 2 clicks with a start date of 2/2/2024. During an observation on 7/29/2024 at 3:18 PM in the Medication room [ROOM NUMBER] with Agency Medication Aide revealed: 1 bottle of aspirin with an expiration date of 4/2024. A refrigerator had medication for Resident #81 for scopolamine 0.2% topical compound filled 2/2/2024 with a discard date of 7/14/24. During an interview on 7/29/2024 at 3:25 PM, the Agency Medication Aide said that she had only been to the facility twice and that day was her second time working at the facility. She said she was not sure who was responsible for checking the medication rooms for expired medications . 2. Record review of an admission Record dated 7/30/2024 for Resident #68 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of chronic systolic heart failure (the heart is weak, and the left ventricle is unable to contract (squeeze) normally when the heartbeat), depression, dementia with agitation, and hypertension. Record review of a care plan for Resident #68 dated 7/4/2023 indicated he had an alteration in neurological status related to dementia with interventions to give medications as ordered. 675998 Page 6 of 18 675998 07/31/2024 Legacy at Town Creek 2212 W Reagan St Palestine, TX 75801

F 0755 Monitor/document for side effects and effectiveness. Level of Harm - Minimal harm or potential for actual harm Record review of a Quarterly MDS Assessment for Resident #68 dated 6/22/2024 indicated he had moderate impairment in thinking with a BIMS score of 8. Residents Affected - Few Record review of active physician orders for Resident #68 dated 7/30/2024 indicated an order for acetaminophen suppository 650 mg, insert 650 mg rectally every 6 hours as needed for pain with a start date of 6/15/2022. During an observation on 7/29/2024 at 4:00 PM in Medication room [ROOM NUMBER] with LVN K revealed: a refrigerator that had 8 rectal suppositories of Tylenol 650 mg for Resident # 68 with a discard date of 7/25/24. During an interview on 7/29/2024 at 4:10 PM, the DON said the facility had three-unit managers who were the ADON's in the facility that were responsible for checking the medication rooms and carts. She said each unit had an assigned unit manager. During an interview on 7/31/2024 at 8:25 AM, the ADON said she had been employed at the facility for a year and was the unit manager for Medication room [ROOM NUMBER]. She said she was responsible for checking the medication rooms and carts weekly for expired medications. She said the last time she checked Medication room [ROOM NUMBER] one day last week. She said she forgot to check the refrigerator that had medications. She said there was a risk of accidentally giving the medications to a resident if the medications were expired. During an interview on 7/31/2024 at 10:10 AM, the DON said she had been employed at the facility since February 2023. She said the ADON's were responsible for checking the medication rooms and carts for expired medications. She said there was a risk of medication errors or if given past their discard or expiration dates, they could be less effective. During an interview on 7/31/2024 at 11:00 AM, the Administrator said the charge nurses and medication aides were responsible for checking the medication rooms and carts with the ADON's as backup. She said there was a risk of decreased effectiveness of if given medications that were past their expiration dates . Record review of a facility policy titled Administering Medications revised December 2012 indicated, .Medications shall be administered in a safe and timely manner, and as prescribed. 9. The expiration/beyond use date on the medication label must be checked prior to administering . Record review of a facility policy titled Storage of Medications revised date of April 2007 indicated, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 4. The facility shall not use discontinued, outdated, or deteriorated drugs and biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed . 675998 Page 7 of 18 675998 07/31/2024 Legacy at Town Creek 2212 W Reagan St Palestine, TX 75801

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 1 of 5 medication storage rooms (Medication room [ROOM NUMBER]) and 1 of 24 residents (Resident #30) reviewed for medication administration. The facility did not ensure medications were not stored at the bedside for Resident #30 on 7/29/2024. The facility failed to ensure Medication room [ROOM NUMBER]'s refrigerator was free of contaminants on 7/29/2024 when it was observed leaking water inside and had a medicine cup of white capsules that water was dripping on. This failure could place all residents at an increased risk of receiving contaminated medications/supplements resulting in adverse health consequences. Findings included: 1.Record review of an admission record for Resident #30 dated 7/30/2024 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of senile degeneration of brain (age related decline in thinking), COPD (a group of lung diseases that make it difficult to breathe), major depressive disorder (a mood disorder that causes persistent feelings of sadness and loss of interest), and muscle wasting (loss of muscle mass). Record review of a care plan for Resident #30 dated 7/15/2022 indicated she had impaired cognitive function/dementia or impaired thought processed related to dementia with interventions that included to administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of active physician orders for Resident #30 dated 7/30/2024 indicated an order for glycopyrrolate capsule (used to treat excessive drooling) 14 mcg give 3 ml by mouth every 4 hours as needed for increased secretions open capsule and mix with 3 ml 0.9% normal saline nebulize with a start date of 7/10/2024. Record review of Medication Administration Record (MAR) for Resident #30 dated 7/1/2024-7/31/2024 indicated an order for glycopyrrolate 14 mcg give 3 ml by mouth every 4 hours for increased secretions with a start date of 7/10/2024 indicated from 7/10/2024-7/30/2024 that the medication was not administered. Record review of a Significant Change MDS assessment dated [DATE] indicated she was unable to complete the interview with a score of 99. Special Treatments, Procedures, and Programs indicated the resident received hospice while a resident. During an observation on 7/29/2024 at 9:46 AM Resident #30 was in bed resting with her eyes closed. There were eleven vials of normal saline on the nightstand next to a nebulizer. 675998 Page 8 of 18 675998 07/31/2024 Legacy at Town Creek 2212 W Reagan St Palestine, TX 75801

F 0761 Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 7/29/2024 at 3:18 PM in the medication storage room with the Agency Medication Aide revealed a refrigerator that was leaking water and had a medicine cup of white capsules that the water was dripping on. She said the white capsules were lactobacillus capsules (used to promote good bacteria in the gut). She said she was not aware that the refrigerator was leaking and would let someone know. Residents Affected - Few During an interview on 7/29/2024 at 3:25 PM, the Agency Medication Aide said that she had only been to the facility twice and that day was her second time working at the facility. She said she was not sure who was responsible for checking the medication rooms for expired medications. During an observation on 7/29/2024 at 3:50 PM in the room of Resident #30 who was not in the room revealed eleven vials of normal saline still on the nightstand. During an interview on 7/29/2024 at 3:52 PM in the room of Resident #30 who was not in the room. LVN E observed the eleven vials of normal saline on the nightstand. LVN E said Resident #30 did not get any scheduled inhalers or nebulizer medications. She said Resident #30 did have a medication that was supposed to be mixed with normal saline. She said she only gave Resident #30 medications prn and had not given her anything that day. She said she was agency staff and her last day worked in the facility was a day the week prior. She said there was a risk of overdose of medication and improper use if medications were left at the bedside. She said medications were not allowed to be left in rooms and must be kept on the medication carts. During an interview on 7/29/2024 at 4:10 PM, the DON said the facility had three-unit managers who were the ADON's in the facility that were responsible for checking the medication rooms and carts. She said each unit had an assigned unit manager. During an interview on 7/31/2024 at 8:25 AM, the ADON said she had been employed at the facility for a year and was the unit manager for Medication room [ROOM NUMBER]. She said she was responsible for checking the medication rooms and carts weekly for expired medications. She said the last time she checked Medication room [ROOM NUMBER] one day last week. She said she forgot to check the refrigerator that had medications. She said there was a risk of accidentally giving the medications to a resident if the medications were expired. During an interview on 7/31/2024 at 10:10 AM, the DON said she had been employed at the facility since February 2023. She said medications should never be left at the bedside because there was a risk of overdose or someone else coming in the room and taking them. She said the ADON's were responsible for checking the medication rooms and carts for expired medications. She said there was a risk of medication errors or if given past their discard or expiration dates, they could be less effective. During an interview on 7/31/2024 at 11:00 AM, the Administrator said she was made aware of medications being left at the bedside and the other meds that were in the refrigerators. She said the charge nurses and medication aides were responsible for checking the medication rooms and carts with the ADON's as backup. She said medications should not be left at the bedside unless a resident had been deemed appropriate to take their own medications. She said there was a risk of decreased effectiveness of if given medications that were past their expiration dates. Record review of a facility policy titled Administering Medications revised December 2012 indicated, .Medications shall be administered in a safe and timely manner, and as prescribed. 9. The expiration/beyond use date on the medication label must be checked prior to administering . 675998 Page 9 of 18 675998 07/31/2024 Legacy at Town Creek 2212 W Reagan St Palestine, TX 75801

F 0761 Level of Harm - Minimal harm or potential for actual harm Record review of a facility policy titled Storage of Medications revised date of April 2007 indicated, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 4. The facility shall not use discontinued, outdated, or deteriorated drugs and biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed . Residents Affected - Few 675998 Page 10 of 18 675998 07/31/2024 Legacy at Town Creek 2212 W Reagan St Palestine, TX 75801

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety requirements and kitchen sanitation. 1. The facility failed to ensure [NAME] wore a hair net effectively to cover all his hair on 7/30/2024. 2. The facility failed to ensure DA wore a hair net effectively and did not have hair out on the front and side of her head not covered by her hair covering on 7/31/24. 3. The facility failed to ensure all foods stored in the refrigerators, freezers, and dry pantry were labeled, dated, and not kept past their expiration dates. 4. The facility failed to ensure proper hand washing between tasks. 5. The facility failed to ensure ovens were clean and free of debris. 6. The facility failed to ensure the ice machine was free from a black, slimy substance. These failures could place residents at risk of foodborne illness and food contamination. Findings included: During an observation of the cooler/refrigerator on 7/29/2024 at 9:30am, the following items were observed: 1 pan of pre-wrapped pancakes with no use by date (out of original package). 1 box of red onions not dated or labeled. 1 box of lettuce wilted, uncovered, use date 7/29/2024. 1 pan of ribs not dated or labeled (out of original package). 675998 Page 11 of 18 675998 07/31/2024 Legacy at Town Creek 2212 W Reagan St Palestine, TX 75801

F 0812 1 10 lb. log of ground beef not dated or labeled. Level of Harm - Minimal harm or potential for actual harm During an observation of the Dairy Cooler on 7/29/2024 at 9:37am, the following items were observed: 1 gallon zip loc bag of cheese slices with no label or date. Residents Affected - Many 1 gallon package of diced chicken no date or label (out of original box). 1 package of beef patties sitting in original box open not sealed. 1 gallon zip loc bag of hamburger buns no date or label. During an observation of the Freezer on 7/29/2024 at 9:46am, the following items were observed: 1 gallon bag of Frozen chicken mushroom gravy with an open date of 3/5/24 with no expiration date. 1 cup of sherbet ice cream half thawed sitting on shelf alone with no expiration date. 1 box of pizza's open in original box uncovered or sealed. 1 gallon bag of Corn nuggets open not labeled or dated. 1 large bag of sweet potatoes with no expiration date. During an observation of the Refrigerator on 7/29/2024 at 9:56am, the following items were observed: 1-box of Whipped topping mix with no expiration date. 1-pan of pre portioned puree bread dated 7/20/24, expired 7/27/24. 1-Pan of pre portioned apple sauce in individual dishes with no expiration date. 1-Pan of pre portioned chocolate pudding in individual dishes with no expiration date. 1 zip loc bag of raisins with no expiration date. 1 pan of prebaked apple cobbler with no label or expiration date. During an observation on 7/29/2024 at 10:00am, the Tilt Cooler was observed with brown and black substance and food particles on both sides. During an observation on 7/29/2024 at 10:01am the oven appliance identified as extra oven and not in use per the DM with brown and black substance on the sides and top of the oven door. During an observation on 7/29/2024 at 10:03am the DM did not wash hands between discarding expired foods and prepping rolls to be cooked for lunch. The DM picked up a can of spray-on prep for rolls and sprayed the rolls, put the can down, and continued discarding expired items without washing hands. 675998 Page 12 of 18 675998 07/31/2024 Legacy at Town Creek 2212 W Reagan St Palestine, TX 75801

F 0812 During an observation of the Pantry on 7/29/2024 at 10:05pm, the following items were observed: Level of Harm - Minimal harm or potential for actual harm 2-quart size bottles of prune juice expired 6/14/2024. 1 container of Dijon mustard expired 5/22/2023. Residents Affected - Many 4-quart size containers of sliced strawberry topping with no received or use by date. During an observation on 7/30/2024 at 10:27am the [NAME] was observed with a baseball cap on with a hair net under it. The hair net was not seen until he pulled off his cap. The [NAME] had hair out in the front, sides, and back of his head. During an observation on 07/31/24 at 9:00 AM the ice machine was observed with a black, slimy substance on the top left and right corners and sides of the ice machine. During an interview on 7/30/24 at 4:00pm the DA said she was designated to date, label, and put food in the freezer as one of her duties. She said she realized she needed to date and label all items when they arrived and add the dates the items were opened and the dates they should be discarded. The DA said she understood that out of date foods could put the residents at risk of getting sick. She said she would make sure things were dated and labeled in the future and would be more cautious of assuring the safety of the food for her residents. During an interview on 7/30/24 at 4:07pm the [NAME] said he was not aware that his baseball cap had raised his hair net off his hair. He said he understood that hair could get in food and cause illness, and he would make other accommodations to assure his hair was completely covered in the future. During an interview on 7/30/24 at 4:10 pm the DA said she did not realize her hair was out in the front and side of her hair covering. She said she understood that all hair should be covered, and it could get into food and that was not sanitary. In the future she said she would assure all her hair was covered. During an interview on 7/30/24 at 4:15pm the DM said she was responsible for all staff to ensure food cleanliness and safety. She did not realize the number of items with no date or label, expired food, hair coverings, or other inappropriate issues. She already started in-services with staff on dating and labeling all items on arrival and when opened and unused. She said she would complete more in-services and assure that in the future all items were properly stored or discarded. She said inappropriately stored food and out of date food put the entire facility at risk of food borne illnesses. During an interview on 7/30/24 at 4:25pm the [NAME] said she did not realize her puree bread was expired and some of her baked goods were not dated or labeled. She said she understood that bad food could make people sick and that in the future she would be mindful of her dates and labels to assure a safer environment for the residents. During an interview on 7/31/24 at 01:55 PM the Administrator said the DM had already begun some in-services regarding the kitchen food storage and sanitation. She said she was responsible for ensuring staff properly wore the hair nets and properly dated, labeled, and discarded expired foods and she expected her staff to follow proper procedures. She said residents could be at risk of food borne illnesses if proper food storage and kitchen sanitation were not followed. 675998 Page 13 of 18 675998 07/31/2024 Legacy at Town Creek 2212 W Reagan St Palestine, TX 75801

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Record review of a facility policy titled Employee Sanitation read .Hairnets, headbands, caps, beard coverings, or other effective hair restraints must be worn to keep hair from food and food-contact surfaces . Facility uses manufacture recommendations to clean the ice machine. Record Review of manufacture recommendations state Hoshizaki recommends .cleaning and sanitizing this unit at least once a year. More frequent cleaning and sanitizing, however, may be required in some existing water conditions . Record review of a facility policy titled Date marking for Food Safety dated 4/14/2024 with revision date of 4/14/2024 read .the facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food . Record review of a facility policy titled Employee Sanitation read .The Nutrition & Food service employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes, in order to minimize the risk of infection and food borne illness . 675998 Page 14 of 18 675998 07/31/2024 Legacy at Town Creek 2212 W Reagan St Palestine, TX 75801

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 review 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 1 of 6 residents (Resident #80) and 1 of 8 staff (CNA F) reviewed for infection control. Residents Affected - Few CNA F did not sanitize or wash her hands between glove changes when providing incontinent care to Resident #80 on 7/30/2024. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings included: Record review of an admission Record for Resident #80 dated 7/31/2024 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of myopathy (disease that makes the muscles weak), atrial fibrillation (irregular heartbeat), major depressive disorder (persistent sadness or loss of interest that interferes with daily life), and hypertension. Record review of a Quarterly MDS Assessment for Resident #80 dated 5/20/2024 indicated she had severe impairment in thinking with a BIMS score of 3. She was dependent on staff for personal hygiene. She was frequently incontinent of bladder/bowel. Record review of a care plan for Resident #80 dated 10/23/2023 indicated she had an ADL self-care performance deficit related to impaired balance with interventions for toilet use: the resident was not toileted. She required assistance of staff x1. During an observation on 7/30/2024 at 10:31 AM, CNA F and CNA G were both in the room of Resident #80 to provide incontinent care. Both washed their hands in the bathroom, and donned (put on) PPE that consisted of a gown and gloves. Resident #80's brief was opened by CNA F and pulled down between her legs. CNA F removed a wipe from the package, wiped the resident's right inner thigh, folded it over, wiped the left inner thigh, and placed the wipe in the trash. CNA G rolled Resident #80 onto her right side. CNA F removed a wipe from the package and wiped Resident #80's rectum from front to back and removed the brief and placed them in the trash. CNA F applied barrier cream to Resident #80's buttocks and removed her gloves and placed them in the trash. CNA F put on gloves without washing or sanitizing her hands and placed a clean brief underneath the resident's buttocks. Resident #80 was rolled onto her left side by CNA G and then positioned onto her back and the brief was secured. CNA F removed her gloves and placed them in the trash, took a shirt out of the dresser drawer, and placed it on the bed. CNA F placed gloves on her hands without washing or sanitizing them, removed the shirt that was on the resident and put it in a laundry hamper. CNA F placed the clean shirt on the resident and repositioned the resident in bed. Both CNA F and CNA G removed their gloves and gown and placed them in the trash. Both washed their hands in the bathroom before exiting the room. During an interview on 7/30/2024 at 10:44 AM, CNA F said she had been employed at the facility for many years. She said during the care provided to Resident #80, she should have used sanitizer between glove changes. She said she just forgot to grab the hand sanitizer and usually kept it in her pocket. She said residents could be at risk for infections. She said she had skills check off on 675998 Page 15 of 18 675998 07/31/2024 Legacy at Town Creek 2212 W Reagan St Palestine, TX 75801

F 0880 incontinent care in the past few months. Level of Harm - Minimal harm or potential for actual harm Record review of a validation checklist for hand hygiene for CNA F dated 6/24/2024 indicated she was satisfactory with hand hygiene. Residents Affected - Few Record review of a skill assessment for CNA F dated 2/8/2024 indicated she was satisfactory with hand hygiene and incontinent care. During an interview on 7/31/2024 at 8:25 AM, the ADON said she had been employed at the facility for a year. She said she and the other the ADON's and the DON were responsible for conducting skill checkoffs with the staff. She said they conduct check offs for new hires before they were allowed to provide direct patient care and yearly thereafter. She said hands should be sanitized or washed before care was started, during care provided, after changing gloves, when going from dirty to clean, and after care was completed. She said there was a risk of passing germs from their hands to someone else if they did not wash or sanitize their hands. During an interview on 7/31/2024 at 10:10 AM, the DON said she had been employed at the facility since February 2023. She said staff should be washing or sanitizing their hands before care, after removing gloves, during care, and after care was provided. She said CNA F had a check off on hand hygiene during incontinent care not long ago and had another one today. She said residents could be at risk for infections if staff did not wash or sanitize their hands. During an interview on 7/31/2024 at 11:00 AM, the Administrator said she was made aware of the incident with hand hygiene not being performed yesterday on 7/30/2024 with CNA F. She said hand hygiene should be performed prior to providing care, after removing gloves, when hands were visibly soiled, when care was completed, and before leaving the room. She said there was a risk for spreading infections if staff did not. Record review of a facility policy titled Hand Hygiene dated 6/13/2024 indicated, .All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . 675998 Page 16 of 18 675998 07/31/2024 Legacy at Town Creek 2212 W Reagan St Palestine, TX 75801

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program and ensure it was free of pests for 2 of 4 halls ([NAME] Lane and [NAME] Center) reviewed for incidents and accidents related to pests. Residents Affected - Few The facility failed to ensure ants were kept out of the rooms and beds for Resident #31 and Resident #75. This failure could place residents at risk for injury due to an ineffective pest control program at the facility. Findings included: 1. Record review of a facility face sheet dated 7/29/24 for Resident #31 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: chronic obstructive pulmonary disease (a common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), convulsions, and history of pulmonary embolism (blood clot located in the lung). Record review of a Quarterly MDS assessment dated [DATE] for Resident #31 indicated that she had a BIMS score of 9, which indicated that she had moderately impaired cognition. She required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. She required supervision with eating. Record review of a comprehensive care plan dated 7/22/24 for Resident #31 indicated she had impairment to skin integrity of the right upper extremity (RUE) related to ant bites. Interventions included to Identify/document potential causative factors and eliminate/resolve where possible. 2. Record review of a facility face sheet dated 7/31/24 for Resident #75 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Sarcopenia (the age-related loss of muscle mass and strength that affects older adults), anxiety disorder, and dementia. Record review of a Quarterly MDS assessment dated [DATE] for Resident #75 indicated that she had a BIMS score of 4, which indicated that she had severely impaired cognition. She required moderate to maximum assistance with bed mobility, dressing, toilet use, and personal hygiene. She required set up help with eating. Record review of a comprehensive care plan for Resident #75 indicated that it did not address ant bites or ants in her room. During an observation and interview on 7/30/24 at 3:30 pm Resident #31 said the bites never itched or bothered her. No bites seen at this time. Bed linen appeared clean. No food was observed in room. No ants were observed in room. Resident #31 had no complaints with facility's handling of the 675998 Page 17 of 18 675998 07/31/2024 Legacy at Town Creek 2212 W Reagan St Palestine, TX 75801

F 0925 incident. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 7/31/24 at 10:00 am Resident #75 was observed in bed asleep. No ant bites were observed. Resident #75 had been moved from her original room while the original room was being treated for ants. LVN M said when she came to work the resident was out of the room and there were some ants by the wall with the window and air conditioner. She said Maintenance had sprayed the room and was told pest control was coming in as well. Residents Affected - Few Record review of an incident report dated 7/16/24 for Resident # 31 read .The resident was noted with several ants in her bed, was noted with 3-4 small bites to her right upper extremity . and .Resident removed from bed, skin assessment, ants removed by maintenance, bed linen changed, and room inspected for ants. Resident was eating in her bed. Area treated . During an interview on 07/30/24 at 3:45 PM the Administrator said no other residents had been bitten. She said that residents could be at risk of an allergic reaction, skin eruption, and itching if they were bitten by ants. She said the maintenance man was responsible for pest control in the facility. During an interview on 7/31/24 at 11:06 AM the Maintenance Man said he treated for ants weekly on the grounds and treated rooms when identified. He said Pest Control also treated when they came once a month. He said he had come today and treated the entire premises along with the room on secured unit that had been identified. He said residents could be at risk if bitten and they were allergic to ants. During an interview on 7/31/24 at 1:57 PM the Administrator said she now has a PIP in place for pest control and they have added a full treatment for fire ants monthly along with their regular treatment. She said the Maintenance Man walks the perimeter twice weekly looking for ants and treats as needed. She said she would also be doing twice monthly rounds with the Maintenance Man looking specifically for ants. She said residents could be at risk of ant bites and allergic reactions if ants were to get inside the facility. Record review of a pest control log form for Pest Control in a binder for [NAME] Lane indicated that staff had seen ants in 3 different rooms on 7/23/24. Record review of a pest control invoice dated 6/19/24 from Pest Control indicated they treated the facility for ants and used a product called FastCap (Esfenvalerate) 6.4% and Delta Dust (Deltamethrin) 0.05%. Invoice indicated that he treated/inspected the exterior perimeter of the facility, the kitchen, landscaped areas, offices, and dishwashing room. Record review of a pest control invoice dated 7/18/24 from Pest Control indicated they treated the facility for ants and used a product called Extinguish (Hydramethylon) 0.365%, Shockwave 1 (Pyrethrins) 0.50%, and Talstar P (Bifenthrin) 7.9%. Invoice indicated that he treated/inspected the dining/break rooms, kitchen, landscaped areas, public areas, and warming area. Record review of a facility policy titled Pest Control Program dated 4/14/24 read .It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents . and .Effective pest control program is defined as measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitos, flies, mice, and rats) . 675998 Page 18 of 18