Health inspection·February 5, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Review of a document titled Resident and Family Grievances, with a revised date of 02/01/2025. Policy Explanation and Compliance Guidelines: . #6. Information on how to file a grievance or complaint will be available to the resident. #8. A grievance may be filed anonymously. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676092 If continuation sheet Page 2 of 7 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 02/05/2025 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 0641 Ensure each resident receives an accurate assessment. 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 accurate assessments were completed for 2 of 10 residents (Resident #17and Resident #54) reviewed for accuracy of assessments. Residents Affected - Few The facility failed to ensure Resident #17's quarterly MDS assessment dated [DATE] was not inaccurately coded for restraint use. The facility failed to ensure Residents #54's admission MDS assessment dated [DATE] was accurately coded for Preadmission Screening and Resident Review (PASRR). These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: 1.A record review of Resident #17's face sheet dated 02/12025 indicated she was a [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses which included chronic obstructive pulmonary disorder (a group of lung diseases that cause airflow obstruction and breathing problems), congestive heart failure (condition where the heart muscle is weakened and cannot pump blood effectively, leading to fluid build-up in the lungs), low back pain, and anxiety. A record review of Resident #17's quarterly MDS dated [DATE] indicated she had a BIMS score of 14 which indicated her cognition was intact and she was able to answer questions. The same MDS indicated Resident #17 had a limb restraint that was being used less than once daily. A record review of Resident #17's physician orders dated from 11/01/2024 to 02/05/2025 revealed there was no order for a restraint during this time. A record review of Resident #17's care plan dated 02/04/2025 did reveal any indication of restraints being used. An observation and interview on 02/03/2025 at 12:18 PM noted Resident #17 lying in bed. She was noted to be alert, oriented to person, place, and time. No restraint was visualized to be in use. During observation and interview on 02/03/2025 at 12:50 PM Resident #17was noted sitting in her recliner, eating lunch. Resident #17 said she was able to transfer herself from her bed to recliner and back. She said she could walk short distances without assistance but could not walk much due to shortness of breath. No restraint was observed to be in use. Resident #17 said she knew what a restraint was, gave examples of restraints, and said she had never had a restraint. An observation on 02/04/2025 at 09:12 AM noted Resident #17 sitting in her recliner in her room. No restraint was noted in use. Resident #17 said she had never had a restraint of any kind. During an interview with the LVN B on 02/04/2025 at 09:15 AM, she said Resident #17 had never had a restraint. During an interview on 02/04/2025 at 09:45 AM, the MDS Nurse said Resident #17 did not require a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676092 If continuation sheet Page 3 of 7 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 02/05/2025 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few restraint. She said the facility was restraint free. When asked about the documentation of restraint use on the quarterly MDS dated [DATE], the MDS Nurse said it was a typo error. The MDS Nurse said the facility used the RAI Version 3.0 Manual as their guideline for completing the MDS accurately. During an interview with the DON on 02/04/2025 at 10:12 AM, she said the facility did not have any restraints is use. She said Resident #17 had never had a restraint and the MDS was coded incorrectly. She said she would get with the MDS nurse and address it. 2. A review of Resident #54's face sheet for February 2025 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included major depressive disorder, anxiety disorder, unspecified psychosis not due to a substance or known physiological condition, Dementia, and insomnia. A review of Resident #54's PASRR Level 1 screening dated 8/24/2020 indicated she was positive for MI. A review of Resident #54's PASRR Evaluation dated 10/16/2020 indicated she was positive for mental illness but did not meet the PASRR definition for mental illness for specialized services. A review of Resident #54's admission MDS dated [DATE] Section A1500. Preadmission Screening and Resident Review (PASRR) indicated No if resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I Active Diagnoses under Psychiatric/Mood Disorder indicated the resident had anxiety disorder, depression. During an interview on 02/05/2025 at 11:15 AM, the MDS Coordinator said the facility used the RAI Version 3.0 Manual as the policy for completing MDS assessments. She said Section A 1500 indicated if the resident was positive for mental illness. She said she did not realize the Section I Active Diagnoses was related to Section A PASRR screening documentation. She said the local authority had found residents that did not qualify for PASRR services because they did not meet the PASRR definition for mental illness for specialized services and thought she had to answer no because they did not qualify for services. She said she did not know Section A had to be coded as positive for mental illness, intellectual disability, or developmental disability even though they did not qualify for PASRR services. During an interview on 02/05/2025 at 1:15 PM the DON said she thought the local authority made the determination whether the resident was positive for a mental illness. She said she thought that indicated they no longer had the mental illness instead of meeting the PASRR definition for mental illness for specialized services. She said it was very confusing since the RAI was not clear. She said the RAI manual was used to ascertain accuracy of the MDS, and she would check with her corporate MDS. A review of the RAI Version 3.0 Manual indicated the following: SECTION P: RESTRAINTS Intent: The intent of this section is to record the frequency over the 7-day look-back period that the resident was restrained by any of the listed devices at any time during the day or night. Assessors will evaluate whether or not a device meets the definition of a physical restraint and code only the devices that meet the definition in the appropriate categories of Item P0100. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676092 If continuation sheet Page 4 of 7 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 02/05/2025 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 0641 Level of Harm - Minimal harm or potential for actual harm . Proper interpretation of the physical restraint definition is necessary to understand if nursing homes are accurately assessing devices as physical restraints and meeting the federal requirement for restraint use (see Centers for Medicare & Medicaid Services. [2007, June 22] Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676092 If continuation sheet Page 5 of 7 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 02/05/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Residents #139) reviewed for Enhanced Barrier Precautions. Residents Affected - Few LVN B failed to don (to put on) a gown prior to administering medications through Resident #139's PICC line (A peripherally inserted central catheter, a thin flexible tube inserted into a vein in the upper arm and threaded into a large vein near the heart. This failure could place residents under their care at risk for the transmission of communicable diseases and infections. Findings included: 1.Record review of a face sheet dated 02/05/2025 indicated Resident #139 was a [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses which included Encephalopathy (a broad term for any brain disease that alters brain function or structure), Sepsis (a life-threatening condition that occurs when the body's immune system has an extreme response to an infection), pneumonia ( infection that inflames air sacs in one or both lungs, which may filled with fluid), acute cystitis ( an inflammation of the bladder, typically caused by a bacterial infection), hemiplegia ( a medical condition characterized by paralysis or weakness on one side of the body), and Type II Diabetes Mellitus. Record review of the quarterly MDS dated [DATE] noted Resident #139 had a BIMS score of 06 which indicated the resident was severely impaired. Record review of the Resident #139's physician orders indicated an order dated 02/01/2025 for Resident #139 to be given Cefazolin in Sodium Chloride Intravenous Solution 2-0.9 GM/100ml - % (Cefazolin sodium Chloride) Use 2 gram intravenously every 8 hours. Route: intravenous piggyback IVBP over 30min via PICC line. During an MED-PASS observation and interview on 02/04/2025 at 2:30 PM, LVN B, verified medication order, medication name, and expiration date on the medication, prepared her intravenous piggyback (IVPB) setup supplies, and the administering IVPB antibiotic (Abx) medication. She obtained the prescribed IVPB Abx., performed hand hygiene, sanitized her hands, and donned a pair of gloves. LVN B did not don the required PPE gown, that she was supposed to for the EBP. LVN B entered Resident # 139's room and informed Resident #139 she was going to administer her IVPB Abx. medication. LVN B performed the necessary premedication assessment, used an antiseptic alcohol wipe to cleanse the port of the main IV line and allowed it to dry, and assessed patency of the resident's IV site for signs of infiltration or inflammation. LVN B, ensured that all air had been removed, hung the IVPB Abx. medication connected to the IV pump, at the correct rate to infused over 30 minutes. After leaving the resident room and returning to the med. cart, LVN B was asked questions concerning Enhanced Barrier Precautions (EBP), she said, she did not don the appropriate PPE (a gown), because she did not think of a PICC line being under the category of a central line, and donning the appropriate PPE was important to reduce the risk of infection. There was no signage to indicate outside Resident #139's door to indicate EBP were necessary. There was no container with PPE in it outside Resident #139's room door. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676092 If continuation sheet Page 6 of 7 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 02/05/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 02/04/2025 at 03:20 PM, LVN C said, she understood what EBP stood for Enhanced Barrier Precaution, and it had to do with infection control. She said, EBP meant staffs were supposed to wear a mask, gown, and gloves when handling catheters and wounds. When surveyor asked LVN C to review the EBP sign on a Resident's door, LVN C read the sign aloud, saying that a gown and gloves were to be used during high-contact resident care activities. LVN C said, the staff had received in-services on infection control and EBP. On 02/05/2025 at 03:30 PM, DON said, she was the Infection Preventionist for the facility. She said, she expected the nurses to follow the facilities policies on infection control and prevention including the policies on EBP. She said, she expected the nurses, and the staff to follow the guidelines of EBPs to reduce the risk for transmission of infection. The DON said, the Charge Nurses reports' Enhanced Barrier Precaution patients to the CNAs, and venders providing direct care at beginning of shifts, and upon arrival daily. The DON said, the purpose of EBP was to reduce the risk of spreading infection. The DON said, LVN B should have donned a gown prior to handling Resident #139 PICC line and hanging the IVPB antibiotic. A record review of the facility's policy dated 04/1/2024 and titled Enhanced Barrier Precautions indicated the following: The policy of this facility is to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. The initiation of Enhanced Barrier Precautions will be obtained for residents with any of the following: Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers), and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes). A record review of the facility's policy dated 2001 MED-PASS, revised July 2014, title Policies and Practices- Infection Control indicated the following: The facility's infection control policies and practices are intended to facilitate, maintain a safe, sanitary, comfortable environment, help prevent, and manage transmission of diseases and infections. The objectives are to establish guidelines for implementing Isolation Precautions, availability and accessibility of supplies and equipment necessary for Standard and Transmission -Based Precautions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676092 If continuation sheet Page 7 of 7