Health inspection·November 21, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 8 residents (Resident #1) reviewed for care plans. The facility failed to develop a comprehensive care plan that included Resident #1's enhanced barrier precautions related to her feeding tube.This failure could place residents at risk of not having individual needs met and cause residents not to receive needed services.Findings included:Record review of Resident # 1's facility face sheet revealed Resident #1 was a [AGE] year-old female and admitted on [DATE] with diagnosis of encounter for gastrostomy (a tube placed in the stomach to assist with feeding). Record review of Resident 1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 indicating intact cognition, relied on staff for all ADL's, was incontinent of bowel and bladder, and required a feeding tube. Record review of Resident #1's comprehensive care plan dated 10/08/2025 revealed Resident #1 required a feeding tube but did not address EBP.Record review of Resident #1's consolidated orders revealed Resident #1 did not have an order for EBP.During an interview on 11/10/2025 at 2:47 pm, the MDS said she was responsible for completing MDS assessments and the comprehensive care plan. She said, with Resident #1, she admitted to the facility with a feeding tube and her comprehensive care plan should have reflected that EBP was required. She said that a comprehensive care plan should have all the resident care areas, interventions and goals. If a care plan was not completed thoroughly and accurately, the residents could have an adverse reaction or change in condition. During an interview on 11/10/2025 at 3:00 pm, the DON said the MDS nurse was responsible for completing the comprehensive care plan accurately and completely. She said that a resident requiring EBP should be care planned as such. She said there was a regional nurse that oversaw the care plans, and they had a plan to start a care plan review to audit all care plans in the facility. She said an incomplete care plan could affect resident care. During an interview on 11/10/2025 at 4:12 pm, the Regional Reimbursement Nurse said that she was responsible for oversight of the care plans, and she had recognized an issue with the care plans last week. She said she had discussed her findings with the team today about a plan to correct them but had not gotten that plan in place. She said inaccurate care plans could result in a lapse of care. During an interview on 11/10/2025 at 4:17 pm, the Administrator said the DON was responsible for the oversight of the care plans, but ultimately fell on her. She said the regional reimbursement nurse came weekly as well and had identified an issue with the care plans last week, but they had not yet put a plan in place to correct the issue. She said they were looking to start an audit today. She said she expected all comprehensive care plans to be completed accurately and thoroughly to prevent delays in resident care. Record review of an undated facility policy titled Comprehensive Care Planning indicated, .The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 676092 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 11/21/2025 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)