Health inspection·January 24, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #42's Care Plan for January 2024 did not reflect Resident #42 was to be allowed to self-administer her own medications. During an observation and interview on 01/22/2024 at 10:33 AM, Resident #42 was noted to be sitting in a wheelchair in her room with an over-the-bed table in front of her. No staff were in the room. Resident was alone. paper towel with 2 (two) small, white pills lying on it was noted on the table top along with a small plastic medication cup with 1 (one) large white capsule and 1 (one) large dark red capsule in it. Resident #42 picked up one of the small white pills and put it into her mouth. After taking a sip of water, Resident #42 picked up the second small white pill, placed it in her mouth and took a sip of water. Resident #42 could not identify what the 2 white pills were. She then pushed the plastic medication cup with the 2 capsules in it back on the table and said she wanted to trade one of the capsules. She could not identify the capsules. Resident #42 said some staff stayed with her until she took her medicine and some of the staff left her medications with her to take on her own. During observations at 10:47 AM, LVN A returned to Resident #42's room, picked up the plastic medication cup with the 2 capsules in it and asked resident #42 why she had not taken those medications. Resident #43 told the nurse that she did not like to take all her medications at the same time and was waiting a little while to take the white capsule. LVN A identified the white capsule as potassium and asked Resident if she would take it. Resident #42 then took the white capsule, placed it in her mouth, and took a sip of water. Resident #42 told LVN A she did not want to take the red capsule and that she wanted to trade it for a tablet of the same drug. Resident #42 told LVN A that she could swallow tablets easier than capsules. LVN said the red capsule was a cranberry supplement and she would check the resident's orders and get back with the resident. During an interview with LVN A on 01/22/2024 at 10:41 AM, she said she left Resident #42's medications on the over-the-bed table for the resident to take. LVN A said she was supposed to stay with the resident until she had taken all her medications. LVN A said the policy for administering medications was for the nurse to stay with the resident to ensure the medications are taken. LVN A did not respond to being asked if there was a reason for leaving the medications at bedside and not ensuring the resident took her medications. During an interview with LVN B on 01/22/2024 at 11:40 AM, she said the nurses were responsible for administering medications to residents. LVN B said nurses were required to stay with each resident until medications were taken and swallowed. During an interview with the DON on 01/22/2024 at 11:05 AM, she said she expected the nurses to stay with the residents when giving medications and ensure they took them. She said residents who did not take their medications were at risk for not receiving the intended therapeutic effect of their medications. She said residents could hoard their untaken medications and risk overdosing themselves and residents who wander may take unattended medications if left sitting out. Record review of the facility's general policy titled Administering Medications including the following: 24. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676092 If continuation sheet Page 2 of 5 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 01/24/2024 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 0755 Record review of the facility's policy titled Administering Oral Medications indicated the following: Level of Harm - Minimal harm or potential for actual harm Purpose The purpose of this procedure is to provide guidelines for the safe administration of oral medications. Residents Affected - Few Steps in the Procedure: 21. Remain with the resident until all medications have been taken. Record review of the facility pharmacy's policy titled Specific Medication Administration Procedures reflected the following: Procedures F. Administer medication and remain with resident while medication is swallowed .Do not leave medications at bedside, unless specifically ordered by prescriber. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676092 If continuation sheet Page 3 of 5 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 01/24/2024 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** Based on observation, interviews, and record review the facility failed to ensure, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 6 residents (Resident #70) reviewed for medication storage. The facility failed to ensure Resident #70's TUMS, an over-the-counter medication, was properly stored. This failure could place residents at risk for adverse reactions . Findings include: Record review of Resident #70's face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #70 had diagnoses which included vascular dementia (problems with reasoning, planning, judgment, and memory caused by lack of blood flow to the brain), cognitive communication deficit (difficulty with any aspect of communication due to an underlying cause), peripheral vascular disease (restricted blood flow to the arms, legs, or other body parts due to blood vessels), hypertension (high blood pressure), and myocardial infarction (Damage to the heart muscle caused by a loss of blood supply to the heart muscle due blockages in the arteries). Record review of the Quarterly MDS , dated 11/08/23, indicated Resident #70 had a BIMS score of 12, which indicated she was moderately impaired cognitively. Record review of the Order Summary Report, dated 1/24/24, indicated Resident #70 had an order for Calcium Carbonate Antacid Tablet Chewable 500 mg, give 1 tablet by mouth every 12 hours as needed for indigestion. Record review of a Medication Administration Record (MAR) for January 2024 indicated Calcium Carbonate Antacid Tablet Chewable 500 mg was not administered as needed to Resident #70. During an observation and interview on 1/22/24 at 11:34 a.m., Resident #70 was in her room sitting in her recliner. There was a half full bottle of TUMS (Calcium Carbonate Name Brand) chewable tablets sitting on top of her refrigerator. Resident #70 said she took medication as needed for indigestion and kept a bottle of TUMS on top of her refrigerator to take. Resident #70 said it had been a while since she last took one and she could not remember the last time she did . During an observation on 1/23/24 at 9:42 a.m., there was a half full bottle of TUMS (Calcium Carbonate Name Brand) chewable tablets in Resident #70's room sitting on top of her refrigerator. During an observation on 1/24/24 at 12:09 p.m., there was a half full bottle of TUMS (Calcium Carbonate Name Brand) chewable tablets in Resident #70's room sitting on top of her refrigerator. During an observation and interview on 1/24/24 at 12:09 p.m., LVN B said she was the nurse responsible for administering medications to Resident #70. LVN B said a resident needed a physician's order (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676092 If continuation sheet Page 4 of 5 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 01/24/2024 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 to administer a medication and to self-administer it. LVN B said all medications should be secured on the medication cart. LVN B said she was unaware Resident #70 had bottle of TUMS in her room. LVN B observed a bottle of TUMS (Calcium Carbonate Name Brand) chewable tablets sitting on top of Resident #70's refrigerator. LVN B said she had been Resident #70's charge nurse for the past three days and never saw the bottle of TUMS on her refrigerator. LVN B said Resident #70 did not have a physician's order to self-administer medications and the bottle should be taken out of her room. LVN B said if medications were not secured and administered by staff a resident was at risk for adverse reactions which could result in hospitalization. LVN B took the bottle of TUMS out of the room and secured it on the medication cart . During an interview on 1/24/24 at 12:23 p.m., the DON said in order for a resident to self-administer medications, a resident had to be evaluated before an order could be written. The DON said a resident needed to be alert, oriented, cognitive, educated, and demonstrate the ability to safely administer their medications to her or someone else on the interdisciplinary team. The DON said medications should be locked up between uses if a resident did not have an order to self-administer medications and expected the nursing staff to look for medications when they entered a resident's room. The DON said she was unaware Resident #70 had a bottle of TUMS in her room. The DON said Residents #70 was not evaluated and did not have an order to self-administer medications. The DON said if medications were not secured and administered by staff a resident was at risk for adverse reactions which could result in hospitalization. Record review of the facility's Self-Administration of Medications policy, revised on 12/2016, indicated Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medication is clinically appropriate for the resident . 8. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or medication room . 9. Staff shall identify and give to the charge nurse any medications found at the bedside that are not authorized for self-administration Record review of the facility's Storage of Medications policy, revised on 04/2007, indicated Policy Statement. The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .2. The nursing staff shall be responsible for maintaining medication storage .7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676092 If continuation sheet Page 5 of 5