Inspection·December 1, 2022

F 0657 10/23/22 fall due to attempted self-transfer from bed (fell in front of bed on knees) resulting in a skin tear to left forearm. Level of Harm - Minimal harm or potential for actual harm 11/02/22 fall due to attempting to reach for books. Residents Affected - Few 11/05/22 fall due to attempting to ambulate without assist. 11/15/22 fall due to attempting self-transfer. 11/25/22 fall due to resident ambulating without assistance resulting in a skin tear and bump to forehead. 11/27/22 fall due to attempted self-transfer from wheelchair to bed resulting in a skin tear to right elbow and forearm. During an interview on 11/30/22 at 2:09 p.m., the DON said they place a new intervention following any falls on the 24-hour report and the nurses communicated this to the CNA'S upon shift huddle. The DON said they have implemented interventions for Resident #78 falls and they should be on his care plan. During a record review of the 24-hour report of the following dates 10/13/22, 10/18/22, 10/23/22, 11/02/22, 11/05/22, 11/15/22,11/25/22, and 11/27/22, did not revealed any fall interventions for Resident #78. During a record review of Resident #78's care plan on 11/30/22 at 4:00 p.m., revealed some updates had been done to the residents care plan related to falls and interventions. The new interventions revealed low bed, enabler bars and remind resident to use assistive device as needed. During an interview on 11/30/22 at 4:35 p.m., CNA P said they usually do a huddle at shift change but she was not aware of individual residents' care plans or where they are located to review resident's needs. During an interview on 12/01/22 at 9:10 a.m., ADON K said they talk about falls in the morning meetings and discuss any interventions needed. ADON K said the MDS nurse was the person responsible for updating the care plans. ADON K said they could have place Resident #78 on a toileting program or other interventions but because of his dementia they did not. ADON K said care plans should be updated to reflect care of residents. During an interview on 12/01/22 at 9:33 a.m., ADON M said they talk about falls in the morning meetings and they meet weekly about falls and follow up if needed. ADON M said the MDS Nurse updated the care plan while in the morning meeting for all interventions. ADON M said she did not touch the care plans but would implement an intervention if not done by the nurses for falls. ADON M said the care plan was used for daily care of the residents. During an interview on 12/01/22 at 9:58 a.m., MDS O said they talk about all changes in the morning meetings and then she usually updated the care plans daily. MDS O said they meet weekly to talk about falls and if they see where they need to add or delete interventions to a care plan it would be done during the meeting. MDS O said she updated Resident #78's care plan with interventions after his falls as discussed in the meetings. MDS O said the care plan was the plan of care and everyone had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676092 If continuation sheet Page 2 of 17 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 676092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Jacksonville 810 Bellaire St. Jacksonville, TX 75766 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few access to the care plan. MDS O said if something was not on the care plan it could potentially change the resident's outcome of care. During an interview on 12/01/22 at 10:30 a.m., the ADM said the process after each fall was to find the root cause and then put intervention(s) in place. The ADM said they talked about falls in the morning meetings and usually the charge nurses started the process, and the ADON/DON followed up. The ADM said he was ultimately responsible for all residents' care. The ADM said without completed care plans it could possibly impede care. During an interview on 12/01/22 at 11:21 a.m., the DON said the charge nurses completed the incident report, added interventions, and discussed with staff at shift huddle. The DON said the ADONs was to follow up on all falls to make sure interventions are in place. The DON said she reviewed the incident reports and if interventions had not been added, she would add them. The DON said they had not tried a toileting plan or had set times to check on Resident #78. The DON said they discussed falls in morning meetings and the MDS Nurse updated the care plan. The DON said she periodically looked at care plans to make sure they was completed. The DON said incomplete care plans could cause care to be missed. Record review of care plan policy dated December 2016, indicated, A comprehensive person-centered care plan that includes measurable objective and timetable to meet the residents physical psychosocial and functional needs is developed and implemented for each resident .#11 Care plan interventions are chosen only after careful data gathering, proper sequence of events, careful consideration of the relationship between the residents problem area and their causes and the relevant clinical decision making . #13 Assessments of residents are ongoing and care plans are revise as information about the resident and the residents' condition changes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676092 If continuation sheet Page 3 of 17 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 676092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Jacksonville 810 Bellaire St. Jacksonville, TX 75766 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 20 residents reviewed for personal hygiene. (Resident #12) Residents Affected - Few The facility failed to ensure Resident #12 received assistance with shaving of her facial hair. This failure could place residents who were dependent on staff to perform personal hygiene at risk of embarrassment, decreased self-esteem, or decreased quality of life. Findings included: Record review of face sheet dated 11/30/22 indicated Resident #12 was a [AGE] year-old female, who admitted to the facility on [DATE], and readmitted on [DATE] with the diagnoses of tremors (shaking), cognitive communication deficit, glaucoma, and contractures (deformity and rigidity of joint) of her right and left hands. Record review of the Medicare MDS 10/28/22 indicated Resident #12 usually was understood, and usually understood others. The MDS in Section C0400 indicated she was unable to recall. Resident #12's BIMS was 0, indicating severe cognitive impairment. The MDS section G0110 indicated Resident #12 required extensive assistance of one staff for personal hygiene including shaving. Record review of a comprehensive care plan dated 03/15/19 indicated Resident #12 had an ADL Self Care Performance Deficit related to limited mobility and limited range of motion. The goal of the care plan indicated Resident #12 would maintain current level of function with her ADLs. The interventions indicated Resident #12 required total assistance from 1-2 staff for hygiene. Record review of the Documentation Survey Report dated 12/01/22 indicated Resident #12 received personal hygiene on 11/27/22 on the evening shift, 11/29/22 on the day shift and evening shift, and on 11/30/22 on the evening shift. During an observation on 11/28/22 at 11:35 a.m. revealed Resident #12 was sitting in her chair in her room. Resident #12 had dark brown and gray colored facial hair on her chin measuring ¼ inches in length. Resident #12 was unable to state if she desired the chin hair to be removed. During an observation on 11/29/22 at 9:15 a.m. revealed Resident #12 continued to have facial hair to her chin and now her upper lip. During an observation and interview on 11/30/22 at 9:04 a.m. revealed LVN D confirmed Resident #12 had facial hair on her chin and upper lip. LVN D indicated the CNAs were responsible for ensuring ADLs were completed. LVN D indicated the nurses were responsible for ensuring the ADLs were completed by the CNAs. LVN D indicated the facial hair should be moved with showers. LVN D indicated she was Resident #12's nurse. LVN D stated a female having facial hair could be a dignity issue due to being embarrassed . During an interview on 11/30/22 at 9:10 a.m., CNA E stated anyone in nursing was responsible for ensuring the residents were shaved . CNA E indicated she did provide care to Resident #12. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676092 If continuation sheet Page 4 of 17 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 676092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Jacksonville 810 Bellaire St. Jacksonville, TX 75766 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/30/22 at 9:14 a.m., CNA F stated she had worked 4 months in the facility. CNA F indicated she did provide care to Resident #12. CNA F stated she was aware of the facial hair on Resident #12's chin and upper lip. CNA F stated she had not had the time yet to remove the facial hair . CNA F stated she would be embarrassed to have facial hair. During an interview on 12/01/22 at 10:15 a.m., the DON indicated the charge nurses were responsible for oversight of the CNAs performing the personal hygiene needs and then the nurse managers were responsible for oversight of the nurses. The DON stated Resident #12 could feel embarrassed to have facial hair. During an interview on 12/01/22 at 11:40 a.m., the Administrator stated it would be great to have no residents with ADL care issues. The Administrator stated the nursing floor staff were responsible for providing personal hygiene. The Administrator stated a woman having undesired facial hair could be a dignity issue. Record review of a Shaving the Resident policy and procedure dated October 2010 indicated the purpose of the procedure was to promote cleanliness, and to provide skin care. Notify the supervisor if the resident refuses the procedure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676092 If continuation sheet Page 5 of 17 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 676092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Jacksonville 810 Bellaire St. Jacksonville, TX 75766 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for resident's needs for 3 out of five licensed staff (LVN A, LVN B, and LVN C) reviewed for skills competency. The facility failed to ensure that LVN A, LVN B, and LVN C, who were all charge nurses for the resident with the tracheostomy, were competent in providing tracheostomy care. This failure had the potential to affect residents by placing them at an increased and unnecessary risk of exposure to staff who lack the appropriate skills competencies to provide care that is safe and capable of minimizing accidents, hazards, and communicable diseases and infections. Findings include: Record review of the Record of In-Service dated 11/02/21 indicated the staff were in-serviced on trach care procedures, setup, and equipment. The in-service also indicated no evidence LVN A, LVN B, and LVN C were a part of the in-service. Record review of the Respiratory Therapy Training Competency checklist revised November 2014 indicated that all hired nursing employees should have been completed initially on hire and annually. Record review of the proficiency checklist in the employee files for LVN A, LVN B, and LVN C indicated no evidence the nurses had been trained or evaluated for tracheostomy care. Record review of the daily staffing attendance schedules dated 11/28/22-11/30/22 indicated LVN B was the charge nurse on the South hall numbers 400-600 for 6PM to 6AM (night) shift, LVN C was the charge nurse for the North hall numbers 100-300 for 6PM to 6AM (night) shift, and LVN A was the charge nurse for South hall number 600 on 11/29/22 on the shift 6AM to 6PM (day) shift. Both LVN B and LVN C worked as the only nurses in the facility on 11/28/22 6PM-6AM (night) shift. Record review of the 672 form for the facility dated 11/28/22 indicated that the facility had 1 resident with a tracheostomy. During an interview on 12/1/22 at 9:34 AM LVN A was the charge nurse for the resident with a tracheostomy on 12/1/22 and said that she did not know how to perform tracheostomy care for the resident with a tracheostomy if he could not provide care himself. LVN A said she had not had a training in which she learned tracheostomy care and had to perform a return demonstration of the knowledge. LVN A said if she was the charge nurse and the resident needed a nurse for tracheostomy care, she would try to find and grab a more seasoned nurse to assist her in caring for the resident. LVN A said she had not been a nurse very long. Attempted to call LVN C on 12/01/22 at 9:49 AM, there was no answer. Attempted to call LVN B on 12/01/22 at 9:50 AM, there was no answer. During an interview on 12/01/22 at 12:43 PM the Administrator said he expected all nurses to be checked off on competencies to care for the residents. He said he was not aware staff were not trained (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676092 If continuation sheet Page 6 of 17 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 676092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Jacksonville 810 Bellaire St. Jacksonville, TX 75766 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete for tracheostomy care. He said ultimately the DON was responsible for training staff on tracheostomy care, and there could be health issues and problems for residents if a nurse on the floor caring for a resident with a tracheostomy did not know how to provide care. During an interview on 12/01/22 at 1:50 PM the DON said they did not have a policy for proficiency. The DON said they only had a policy for staff development. She said it was important for nurses to be in-serviced and checked off on tracheostomy care when they had a resident with a tracheostomy. The DON said not being trained could cause a resident harm, but the resident performed his tracheostomy care himself. The DON said there were several scenarios that could come about but a nurse could always get help from another nurse in the building. The DON said she is responsible for ensuring all nurses were competent in providing care to residents and the Corporate Respiratory Therapist would come whenever she called her for her to provide tracheostomy training. Event ID: Facility ID: 676092 If continuation sheet Page 7 of 17 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 676092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Jacksonville 810 Bellaire St. Jacksonville, TX 75766 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record, and residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 resident of 6 residents reviewed (Resident #9) for unnecessary medications. The facility failed to attempt a gradual dose reduction for the medication Seroquel 25mg ½ tab every night, originally ordered on 02/09/22 for Resident #9. Resident #9 was administered an antipsychotic, Seroquel (quetiapine fumarate), to treat adjustment disorder with mixed anxiety and depressed mood and never received an attempted gradual dose reduction. This failure could place residents at risk of receiving unnecessary medications. Findings include: Record review of Resident #9's admission Record dated 11/30/22 indicated Resident was a [AGE] year-old male who originally admitted to the facility on [DATE] and had re-admitted on [DATE] with the diagnoses of Alzheimer's disease, adjustment disorder with mixed anxiety and depressed mood, diabetes, and metabolic encephalopathy (acute confusion). Record review of Resident #9's MDS dated [DATE] indicated the resident had a short-term and long-term memory problem with severely impaired cognition. He could not complete a BIMS assessment. The MDS indicated the resident required extensive assist of one person for bed mobility, transfers, toileting, eating, dressing, personal hygiene, and he required total assistance of one person for bathing. The MDS also indicated the resident received 7 days of an antipsychotic medications in the look back period with no gradual dose reduction being attempted. Record review of Resident #9's care plan revised on 01/07/22 indicated that resident used a psychotropic medication (Seroquel) related to delusions. Record review of Resident #9's Order Summary Report dated 11/30/22 indicated the resident had an order for: Seroquel 25mg tab ½ tab by mouth at bedtime for agitation related to adjustment disorder with mixed anxiety and depressed mood. A ½ tab equal to 12.5mg that restarted on 02/09/22, discontinued on 5/16/22 and re-started on 05/16/22. Record review of the Psychotropic & Sedative/Hypnotic Utilization By Resident dated 08/07/22, 09/08/22, and 10/22/22 indicated Resident #9 was ordered Seroquel (Quetiapine Fumarate tab 25mg tab1/2 (12.5mg) every night at bedtime started on 02/09/22 and a gradual dose reduction had not been performed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676092 If continuation sheet Page 8 of 17 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 676092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Jacksonville 810 Bellaire St. Jacksonville, TX 75766 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the Psychotropic & Sedative/Hypnotic Utilization By Resident dated 11/20/22 indicated that Resident #9 was ordered Seroquel (Quetiapine Fumarate tab 25mg tab1/2 (12.5mg) every night at bedtime started on 02/09/22 and a gradual dose reduction was recommended by the pharmacy consultant but the form had not been sent to the physician or noted. During an interview on 12/02/22 at 10:49 AM with the DON, she said when residents received a new order for an antipsychotic medication it should be evaluated in 14 days and the pharmacist should have been monitoring the medications monthly. The DON said they had a pharmacy consultant that came in monthly to review all resident medications and Resident #9 had been monitored. She said the gradual dose reduction should have been performed within the first quarter of the medication begin date. She stated she guessed they missed it. The DON said Resident #9's medication Seroquel was started on 02/09/22 after a different medication was discontinued because it was requested by Resident #9's family member. The DON said she knew that antipsychotic medications should not be given to residents with dementia and Alzheimer's. She said Resident #9 had a diagnosis of adjustment disorder, but he did not have a diagnosis for mental illness. The DON said she knew he should not have been on the medication. She said the failure in not having a gradual dose reduction for an antipsychotic medication or a proper diagnosis could be a disservice to resident and potentially result in harm. The DON said she was responsible for monitoring the pharmacy recommendations monthly and had one for Resident #9 dated 11/19/22 but had not had the time to send to the physician. During an interview on 12/01/22 at 12:37 PM with the Administrator, he said the pharmacy consultant and the nurse managers should have been monitoring resident medications, but the DON was ultimately responsible for ensuring the residents' medications have a proper diagnosis for use and were being monitored correctly. The Administrator said monitoring antipsychotic medications was very important for compliance reasons and there could have been a resident not being at a therapeutic dose. He said there were also risks with giving antipsychotic medications to residents with dementia. Record review of the facility policy for Antipsychotic Medication Use indicated . Policy Statement Antipsychotic medications may be considered for resident with dementia after medical, physical, functional, psychological, emotional psychiatric, social and environmental causses of behavioral symptoms have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. Policy Interpretation and Implementation 1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective .4. The Attending Physician and the facility staff will identify acute psychiatric episodes and will differentiate them from enduring psychiatric conditions .6. Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident. 7. Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676092 If continuation sheet Page 9 of 17 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 676092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Jacksonville 810 Bellaire St. Jacksonville, TX 75766 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - 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** 2. Record review of a face sheet dated 11/30/22 indicated Resident #74 was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of rectal abscess, high blood pressure, and anemia. Record review of a Quarterly MDS dated [DATE] indicated Resident #74 was understood and understood others. The MDS indicated Resident #74 memory was intact. Record review of the comprehensive care plan dated 02/28/22 indicated Resident #74 had impaired memory cognitive function or impaired thought process related to short term memory loss. The goal was Resident #74 would maintain a current level of cognitive function. The interventions for Resident #74 included asking yes or no questions, communicate with the resident, family, caregivers, regarding Resident #74's capabilities. During an observation and interview on 11/28/22 at 11:05 AM revealed Resident #74 had plastic medication cups on her over the bed table. Two of the medication cups were full of a brown liquid and the third had numerous tablet and capsule form medications. During an interview with Resident #74 she stated one of the brown liquids was last night's medication and the other two were the medications from this morning . Record review of the consolidated physician's orders dated 11/30/22 indicated Resident #74 orders for: *Vitamin C 500 mg one tablet by mouth daily *Colace Capsule 100 mg one capsule by mouth daily *Ferrous Sulfate 325mg one by mouth two times daily *Metoprolol Tartrate 25 mg give 12.5 mg twice daily *Multivitamin with Minerals one table by mouth daily *Potassium Chloride Extended Release 20 milliequivalents one tablet by mouth daily *Protein liquid 30 milliliters by mouth twice daily *Sodium chloride 1 gram one tablet by mouth daily *Vitamin B12 one tablet by mouth daily *Zinc 50 mg one by mouth daily During an interview on 11/28/22 at 11:10 AM RN H stated she was responsible for the care of Resident #74. RN H stated the medications at bedside could cause Resident #74 to receive a double dose of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676092 If continuation sheet Page 10 of 17 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 676092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Jacksonville 810 Bellaire St. Jacksonville, TX 75766 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medications and/or another resident could access the unsecured medications . RN H said she would ask MA N why the medications were left at the bedside. During an interview and record review on 11/28/22 at 11:20 AM MA N stated she had left the medications at Resident #74's bedside. MA N reviewed the medication administration record and noted the medications were vitamin C, Colace, Iron Sulfate, metoprolol, multivitamin with minerals, [NAME] flu, Potassium extended release, Sodium, Vitamin B12, Vitamin D3, and Zinc. MA N said Resident #74 was not ready to take the medication and request the medication be left at bedside. MA N stated leaving medications at bedside could cause a resident to get multiple medications too close together or another resident could take them by mistake. Record review of MA N's Clinical Proficiencies including medication administration was completed on 11/17/22. Record review of MA N's Medication Administration Skills Assessment completed on 11/17/22 indicated MA N passed the assessment in the areas of: 12. Resident observed to ensure medications are swallowed 14. Medications are not left on top of the cart or at the residents bedside 15. Refused/withheld medications are properly noted. Notify the MD. During an interview on 12/01/22 at 10:31 a.m., the DON stated the medications should be kept by the nurse or medication aides. The DON stated the facility used champion rounds to monitor for areas of concern that required correction. The DON stated leaving medications at bedside could lead to anyone taking the medications. During an interview on 12/01/22 at 11:40 AM the Administrator stated medications should not be kept at bedside. The Administrator stated the nursing was responsible for ensuring medications were stored properly. The Administrator stated the blood pressure medication left at bedside could affect another resident's blood pressure. Record review of a Storage of Medication policy and procedure dated April 2007 indicated the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 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, included the appropriate accessory and cautionary instructions, the expiration date when applicable and stored all drugs and biologicals in locked compartments for 2 residents (Resident #65 and Resident #74) of 20 in the sample. The facility did not ensure Resident #65's Artificial Tears were properly stored. The facility did not ensure Resident #74's medications were properly stored by leaving them at the bedside. This failure could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications, or harm by ingestion. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676092 If continuation sheet Page 11 of 17 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 676092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Jacksonville 810 Bellaire St. Jacksonville, TX 75766 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Findings: Level of Harm - Minimal harm or potential for actual harm Record review of Resident #65's admission Record dated 11/30/22 indicated that resident was an [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of chronic obstructive pulmonary disease (lung disease), atrial fibrillation (increased heart rates), macular degeneration (eye problem), diabetes, and dementia. Residents Affected - Few Record review of Resident #65's MDS dated [DATE] indicated the resident had a BIMS of 14 which meant he was cognitively intact. The MDS also indicated the resident was independent with bed mobility, transfers, and eating. He required supervision with toileting, person hygiene, and bathing. Record review of Resident #65's care plan dated 3/11/21 indicated Resident #65 had a problem of impaired visual function related to macular degeneration, dry eyes with no interventions of eye drops. During an observation on 11/28/22 at 11:40 AM revealed Resident #65 had a bottle of artificial tears sitting on his bed side table. During an observation on 11/29/22 at 09:06 AM revealed Resident #65 had a bottle of artificial tears remained on the bed side table. During an interview on 11/30/22 at 9:50 AM Resident #65 said he had an eye surgery, and he had the bottle of artificial tears on the bed side table because he used them as needed because his eyes dried out at times. Record review of Resident #65's Order Summary Report dated 11/30/22 indicated Resident #65 did not have an order for artificial tears. During an interview on 11/30/22 at 10:02 AM with LVN A, she said no residents in the facility should have had medications in their rooms, and that no one self-medicated. She said all medications were to be locked in the medication carts or in the medication room. LVN A said if a resident had a medication in their room, it could place that resident or other residents at risk of overuse. LVN A also said the resident could have allergies to medications and could be a risk if the nurse was unaware of the use. LVN A said she was unaware of Resident #65 having the artificial tears at his bedside. She said other residents could have picked up the medication and used it, swallowed it, or overdosed. LVN A said she would have removed the medication and notified the doctor for orders if Resident #65 needed the medication. During an interview on 12/01/22 at 10:32 AM with the DON, she said all medications should be kept by the nurse on the medication carts, whether they were over the counter or prescription. She said she was unaware Resident #65 had eye drops in his room. The DON said all staff had responsibility of ensuring medications were not in resident rooms. She said they performed champion rounds daily to check resident rooms for issues as well as items that should not be in the rooms. The DON said when residents had medications in their rooms it placed a risk for other resident to retrieve the medications, and misuse the medications. During an interview on 12/01/22 at 12:37 PM with the Administrator, he said medications should not be kept at the bed side. He said nursing staff were responsible for ensuring residents did not have medications in rooms. The Administrator said there was always a potential risk for residents with medications at the bed side, but he did not think a resident would overdose from eye drops. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676092 If continuation sheet Page 12 of 17 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 676092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Jacksonville 810 Bellaire St. Jacksonville, TX 75766 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the arbitration agreement contained all the required elements for 1 of 20 residents reviewed for arbitration. (Resident #44) Residents Affected - Few The facility did not ensure the arbitration agreement contained the required elements: *Failed to ensure the arbitration agreement was explained in a form and manner including a language the resident or representative understood *Failed to explain the right not to sign the agreement as a condition of admission. *Failed to provide the right to rescind in 30 calendar days of signing These failures could place the residents or the residents' responsible parties in binding agreements not fully understood, have a loss of their legal rights, and cause negative psychological issues. Findings included: Record review of a face sheet dated 12/01/22 indicated Resident #44 was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of dementia, and cognitive communication deficit . The face sheet indicated Resident #44's daughter was her Responsible Party and emergency contact. Record review of an admission MDS dated [DATE] indicated Resident #44 was Hispanic or Latino. The MDS indicated she usually was understood and usually understands. The MDS indicated she had severe cognitive impairment. Record review of the Comprehensive Care Plan dated 09/12/2022 and updated on 11/28/22 indicated Resident #44's primary language was Spanish. The intervention for this care plan need was to provide a translator as necessary to communicate with the resident. During an interview on 11/29/22 at 10:18 a.m., the Responsible Party stated Resident #44's admission Agreement and Arbitration Agreement was signed by another family member . The Responsible Party stated she had asked the Admissions Specialist to provide her with a copy of the admission Agreement and Arbitration Agreement due to the fact Resident #44 and her spouse neither completely understood English nor spoke English. Resident #44's Responsible Party stated she had not been given the opportunity read and review the forms prior to the signing by her parents. The Responsible Party indicated Resident #44 was not informed of what she was signing. Record review of undated admission Agreement included: In Consideration of the mutual promises contained in this agreement, the parties agree as follows: l.1. Terms and Terminations: Patient/Resident agrees to reside in the Health Care Center. This agreement shall remain in effect until terminated by Patient/Resident in accordance with applicable law or terminated by the Health Care Center as provided in Article IV. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676092 If continuation sheet Page 13 of 17 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 676092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Jacksonville 810 Bellaire St. Jacksonville, TX 75766 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 0847 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few lll. 1. Patient/Resident Responsibilities: Patient/Residents shall abide by the reasonable policies and rules of the Health Care Center which are included herein by reference. V.5. Complete Agreement: This Agreement, the Agreement Addendum (s), and the documents list on the Acknowledgement page attached to this Agreement and made a part hereof constitute the entire agreement between the parties. The Agreement may not be amended except in writing executed by the parties or the successors. VI. Arbitration: Pursuant to the Federal Arbitration Act, any action, dispute, claim or controversy of any kind (e.g., whether in agreement or in tort, statutory or common law, legal or equitable, or otherwise) now exists or hereafter arising between the parties in any way arising out of pertaining to or in connection with provision of health care services, any agreement between the parties, the provision f other goods or services by the Health Care Center or other transactions, agreements or agreements of any kind whatsoever, any part present or future incidents, omissions, acts, error, practices or occurrence causing injury to either party where by the other party or its agents, employees or representatives may be liable in whole or in part, or any other aspects of the past, present, or future relationships between the parties shall be resolved by binding arbitration administered by the National Arbitration Forum. The undersigned Acknowledge that each of them has read an understood this agreement, and that each of them voluntarily consents to all its terms. Review of the Arbitration agreement revealed inside of the admission Agreement was only provided in English. The Arbitration Agreement was a portion of the admission Agreement. The total agreement provided one signature line. The Agreement did not contain separated signature lines where a declination was possible without declining the admission Agreement. The admission Agreement with the Arbitration Agreement did not provide a timeframe of 30 days for declination from the Arbitration Agreement. The admission Agreement with the Arbitration Agreement did not express the Arbitration Agreement would not affect admission to the facility. Record review of Resident #44's admission Agreement: Dispute Resolution Plan page 16: It is hereby agreed and understood that any dispute, difference and /or disagreement of any kind whatsoever, whether statutory or contractual, which arises from the services and/or products provided or relating in any way to the general business relationship of the parties to this agreement, shall be, as the sole available remedy, resolved through mandatory mediation and/or binding arbitration, rather than litigation. The parties agree and acknowledge that the business relationship involves interstate commerce and that nay such mediation or arbitration shall be governed by the Federal Arbitration Act (FAA) and conducted in accordance with the Rules of Mediation and Arbitration as then in effect and administered by the Dispute Solutions, Inc. The cost of any arbitration hereunder, including the cost of the record or transcripts thereof, if any, administrative fees, attorney's fees and all other fees involved, shall be paid by the party determined by the arbitrator to be the prevailing party, or otherwise allocated in an equitable manner a determined by the arbitrator. Record review of the Dispute Resolution Plan revealed on page 64, The Federal Arbitration Act has been around since the 1920's and arbitration is widely used today to resolve problems. The Dispute Resolution Plan is required and the mandatory way for all residents and the Health Care Center to resolve any potential legal problems. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676092 If continuation sheet Page 14 of 17 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 676092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Jacksonville 810 Bellaire St. Jacksonville, TX 75766 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 0847 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/28/22 at 3:00 p.m., the admission Specialist stated she assisted Resident #44's spouse and generally all the responsible party/resident s with signing of the admission Agreement and Arbitration Agreement. The admission Specialist indicated the spouse was present in the facility therefore she asked him to sign the agreement. The admission Specialist stated there had been only one family refuse to sign the Arbitration Agreement since 2020. The admission Specialist stated there were no Arbitration Agreements in other languages, in particularly Spanish. The admission Specialist stated Resident #44's spouse was not provided the Arbitration in his first language of Spanish due to the fact she does not speak Spanish and could not provide him with a clear understanding of agreement. The admission Specialist the Arbitration Agreement did not contain a declination timeframe. During an interview on 12/01/22 at 10:33 a.m., the DON stated she had never read the Arbitration Agreement. The DON stated no one had been refused admission related to the Arbitration Agreement. The DON stated by not providing the Arbitration Agreement in a language the resident or responsible party understood could cause them to enter in an agreement without being fully informed. During an interview on 12/01/22 at 11:40 a.m., the Administrator stated the cooperation had not updated the Arbitration Agreement with the new regulation therefore the agreement was missing required key elements. The Administrator stated not providing the Arbitration in a language understood by the responsible party/resident could cause there to be a binding agreement not fully understood. During an interview on 12/01/22 at 11:50 a.m., the Administrator stated there was not a policy related to Arbitration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676092 If continuation sheet Page 15 of 17 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 676092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Jacksonville 810 Bellaire St. Jacksonville, TX 75766 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 0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure the Arbitration Agreement included the provision of a neutral arbitrator, a convenient venue, and the retention of resolution for 5 years for 1 of 1 facility reviewed for Arbitration Agreements. Residents Affected - Few The facility failed to ensure the Arbitration Agreement contained a section indicating the provision of a convenient venue. The facility failed to ensure the Arbitration Agreement contained the requirements of retention of the resolutions. These failures could place the residents or the residents' responsible parties in binding agreements not fully understood, have a loss of their legal rights, and cause negative psychological issues. Findings included: Record review of the undated admission Agreement included: In Consideration of the mutual promises contained in this agreement, the parties agree as follows: l.1. Terms and Terminations: Patient/Resident agrees to reside in the Health Care Center. This agreement shall remain in effect until terminated by Patient/Resident in accordance with applicable law or terminated by the Health Care Center as provided in Article IV. lll. 1. Patient/Resident Responsibilities: Patient/Residents shall abide by the reasonable policies and rules of the Health Care Center which are included herein by reference. V.5. Complete Agreement: This Agreement, the Agreement Addendum (s), and the documents list on the Acknowledgement page attached to this Agreement and made a part hereof constitute the entire agreement between the parties. The Agreement may not be amended except in writing executed by the parties or the successors. VI. Arbitration: Pursuant to the Federal Arbitration Act, any action, dispute, claim or controversy of any kind (e.g., whether in agreement or in tort, statutory or common law, legal or equitable, or otherwise) now exists or hereafter arising between the parties in any way arising out of pertaining to or in connection with provision of health care services, any agreement between the parties, the provision of other goods or services by the Health Care Center or other transactions, agreements or agreements of any kind whatsoever, any part present or future incidents, omissions, acts, error, practices or occurrence causing injury to either party where by the other party or its agents, employees or representatives may be liable in whole or in part, or any other aspects of the past, present, or future relationships between the parties shall be resolved by binding arbitration administered by the National Arbitration Forum. The undersigned Acknowledge that each of them has read an understood this agreement, and that each of them voluntarily consents to all its terms. Record review of the admission Agreement : (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676092 If continuation sheet Page 16 of 17 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 676092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legacy at Jacksonville 810 Bellaire St. Jacksonville, TX 75766 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 0848 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Dispute Resolution Plan page 16: It is hereby agreed and understood that any dispute, difference and /or disagreement of any kind whatsoever, whether statutory or contractual, which arises from the services and/or products provided or relating in any way to the general business relationship of the parties to this agreement, shall be, as the sole available remedy, resolved through mandatory mediation and/or binding arbitration, rather than litigation. The parties agree and acknowledge that the business relationship involves interstate commerce and that nay such mediation or arbitration shall be governed by the Federal Arbitration Act (FAA) and conducted in accordance with the Rules of Mediation and Arbitration as then in effect and administered by the Dispute Solutions, Inc. The cost of any arbitration hereunder, including the cost of the record or transcripts thereof, if any, administrative fees, attorney's fees and all other fees involved, shall be paid by the party determined by the arbitrator to be the prevailing party, or otherwise allocated in an equitable manner a determined by the arbitrator. Record review of the Dispute Resolution Plan revealed on page 64 of the admission Agreement, The Federal Arbitration Act has been around since the 1920's and arbitration is widely used today to resolve problems. The Dispute Resolution Plan is required and the mandatory way for all residents and the Health Care Center to resolve any potential legal problems. During an interview on 11/28/22 at 3:00 p.m., the admission Specialist stated she assisted the responsible party/resident with signing of the admission Agreement and Arbitration Agreement. The admission Specialist stated there had been only one family refuse to sign the Arbitration Agreement since 2020. The admission Specialist indicated all admissions receive the same admission Agreement. During an interview on 12/01/22 at 10:33 a.m., the DON stated she had never read the Arbitration Agreement. The DON stated no one had been refused admission related to the Arbitration Agreement. The DON stated the Arbitration Agreement should be updated to include the required elements. During an interview on 12/01/22 at 11:40 a.m., the Administrator stated the corporation had not updated the Arbitration Agreement with the new regulation and the requirements therein. The Administrator stated the Arbitration Agreement failed to address the selection of a convenient venue for both parties. During an interview on 12/01/22 at 11:50 a.m., the Administrator stated there was not a policy related to Arbitration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676092 If continuation sheet Page 17 of 17