Health inspection·September 14, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record review, the facility failed to implement their written policies and procedures that prohibit and prevent abuse and neglect for two (CNA D and CNA E) of 10 employees reviewed for employee files. Residents Affected - Some The facility failed to ensure the facility had a copy of criminal background checks conducted prior to hire for CNA D and CNA E. This failure could place residents at risk for abuse and receiving care from unemployable staff. Findings included: Review of facility's policy Abuse Prevention Program undated reflected The facility must develop and implement written policies and procedures that: As part of the resident abuse prevention, the administration will implement the following protocols: .2. Conduct employee background checks and will not knowingly employ or otherwise engage any individual who has: been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law . Review of facility's policy Personnel and Staffing Background Screening Investigations undated reflected The director of personnel, or designee, conducts background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law) on all potential direct access employees and contractors. Background and criminal checks are initiated within 2 days of an offer of employment or contract agreement, and completed prior to employment. Review of facility's policy Licensure, Certification and Registration of Personnel effective May 10, 2022 reflected facility conducts employment background screening checks .and criminal conviction investigation checks in accordance with current federal and state laws. Review of CNA D's personnel file reflected the hire date was 03/30/11 with no criminal background check completed in her file. Review of CNA E's personnel file reflected the hire date was 12/29/11 and there was no criminal background check in her file. Interview on 09/14/23 at 3:11 PM with HR Manager revealed that each employee received an offer of employment letter for hire. Interview revealed the employee then gave the facility permission to conduct the criminal background check. The HR Manager stated the facility conducted the background check before the employee worked at the facility. Interview revealed CNAs D and E worked at the facility for over 13 years and the records were paper. The HR Manager stated the facility did not have the Page 1 of 12 676189 676189 09/14/2023 The Legacy at Willow Bend 6101 Ohio Ste 500 Plano, TX 75024

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some criminal background checks in their files anymore. The HR Manager stated the criminal background checks were only ran again as needed Interview on 09/14/23 at 3:18 PM with the Administrator revealed that it was the facility's policy to run criminal background checks upon hire for new employees but the facility did not have a copy of it for CNA D and CNA E. She stated the purpose of completing these checks were to protect the residents from harm/persecution at the hands of any staff that we hire. Review of CNA D and CNA E's criminal background checks completed on 09/14/23, after surveyor intervention, reflected both CNA D and CNA E were employable and had no bars to employment. 676189 Page 2 of 12 676189 09/14/2023 The Legacy at Willow Bend 6101 Ohio Ste 500 Plano, TX 75024

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 observations, interview, and record review, the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Residents #38) of 19 residents reviewed for comprehensive care plans. 1. The facility failed to develop a care plan for Resident #38's preferences to stay in room and for independent activities in her room. 2. The facility failed to develop a care pan to address Resident #38's pain management. These failures could affect the residents by placing them at risk for possible adverse side effects, adverse consequences, and decreased quality of life and care. Findings included: Review of Resident #38's annual MDS assessment dated [DATE] reflected Resident #38 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of atrial fibrillation (irregular heart rhythm, coronary artery disease (narrowing of the heart major blood vessels that limit blood flow to the heart)., stress fracture of left fibula ( the long bone in the lower leg) , muscle wasting and atrophy, lack of coordination and abnormalities of gait and mobility. Resident #38 had a BIMS of 13 indicating she was cognitively intact. Resident #28 required limited to extensive assistance with all ADLs. Review of Resident #38's Comprehensive Care Plan last revised on 08/29/23 reflected Resident #38 has an ADL self-care performance deficit [related to] impaired balance. Review revealed it did not reflect her preference to stay in her room. It reflected Resident #38 has little or no activity involvement related to mobility. Interventions included to invite and encourage the resident's family members to attend activities with resident in order to support participation, monitor/document for impact of medical problems on activity level, remind resident may leave activities of any time, and was not required to stay for entire activity, resident needs assistance/escort to activity functions. It did not reflect about Resident #38's preference to do independent activities in her room instead of group activities and what activity preferences Resident #38 liked. The care plan did not address about Resident #38's pain. Observation and interview on 09/12/23 at 10:50 AM revealed Resident #38 was lying in her bed and had a book she was reading in her hands. Resident # 38 stated she liked to read and preferred to stay in her room and not participating in group activities. She stated she liked to read and enjoyed reading books. She stated she had arthritis pain and preferred to stay in her bed due to increased pain. Resident #38 stated she was provided pain medications when needed and they were effective to alleviate her pain. Interview on 09/14/23 at 1:25 PM with the MDS Coordinator revealed she thought Resident #38 came out of her room and was unaware she preferred to stay in bed. She stated Resident #38's pain was not care planned since it was not constant pain and did not cause her a problem. She stated the Lifestyle Coordinator was responsible for care planning about resident's activities. 676189 Page 3 of 12 676189 09/14/2023 The Legacy at Willow Bend 6101 Ohio Ste 500 Plano, TX 75024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 09/14/23 at 1:27 PM with Resident Care Coordinator B revealed Resident #38 preferred to stay in her room and in bed. Interview on 09/14/23 at 1:50 PM with DON revealed Resident #38 took Gabapentin for neuropathy and her pain was controlled. She stated Resident #38's pain did not need to be care planed unless it iswas a problem and resident complained of pain. She stated Gabapentin was a minor pain medication compared to narcotic pain medication. She stated the care plan should be resident centered. Interview on 09/14/23 at 2:05 PM with the Lifestyles Coordinator revealed Resident #38 preferred to stay in her room and was independent with her activities like reading books. He stated he visited her in her room regularly and was looking for finding a volunteer who could regularly come visit one-on-one with Resident #38 in her room. He stated he had not updated her care plan to address her preference for staying in the room and reading books. Interview on 09/14/23 at 2:09 PM with RN C revealed Resident #38 preferred to stay in her room and most of the time would be reading a book in her room. He stated Resident #38 took scheduled Gabapentin and would complain of pain or discomfort if getting up in her chair. RN C stated Resident #38 preferred a bed bath. Review of facility's policy Care Plans, Comprehensive Person-centered undated reflected to develop and implement comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs for each resident .7. The care planning process will: b. include an assessment of the resident's strengths and needs; and c. incorporate the resident's personal and cultural preferences in developing the goals of care. 8. The comprehensive, person-centered care plan will: .b. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 676189 Page 4 of 12 676189 09/14/2023 The Legacy at Willow Bend 6101 Ohio Ste 500 Plano, TX 75024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 1 (Resident #24) of 8 residents reviewed for pharmacy services and for 1 (5400 hall nurses' medication cart) of 3 medication carts reviewed for pharmacy services in that: The facility failed to ensure: 1The facility failed to ensure medications were not left unsecured at bedside of Resident #24 2The facility failed to ensure LVN J and LVN N counted controlled drugs on the 09/12/23 night shift/morning shift change. These failures could place residents at risk of not receiving the intended therapeutic benefit of the medication and the risk of not having the medication available due to possible drug diversion Findings Included: 1Observation on 09/12/23 at 10:47 AM, of the room [ROOM NUMBER] revealed a pink oval tablet in a medication cup was on the bed side table unattended. Resident #24 was not in the room. Interview on 09/12/23 at 10:55 AM, LVN J stated she did not leave the pill in the resident's room unattended. She stated she did not know who left the medication in the room unattended. She stated that placed everyone at risk of receiving medication not intended for them; could cause serious health problems. Interview on 09/14/23 at 1:30 PM, the DON stated medications should never be left at bedside. The DON stated she was responsible for in-services on medication administration. The DON stated unsecured meds were a risk to everyone with potential to cause serious illness and could also be a choking hazard. 2During a record review and random count observation of 5400 hall nurses' medication cart with LVN J on 09/12/2023 at 2:26 PM revealed missing signature for 1 tablet of tramadol given to Resident #48. The blister pack count was 22 and the narcotic count sheet was 23. Interview on 09/12/2023 at 2:28 PM, LVN J stated she did not count with the night shift nurse, LVN 676189 Page 5 of 12 676189 09/14/2023 The Legacy at Willow Bend 6101 Ohio Ste 500 Plano, TX 75024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few N, because LVN N was rushing because she had an emergency. LVN J stated she should have counted with LVN N during change of shift. LVN N stated this failure could have potentially caused a drug diversion. An attempted telephone interview on 09/12/2023 at 3:22 p.m. with LVN N, was unsuccessful. Interview on 09/14/2023 at 1:30 PM, the DON stated she expected nurses to count narcotic at the beginning and at the end of their shift with the incoming and off-going nurse. The DON stated this was monitored monthly by the pharmacy consultant. The DON stated she had never really had a problem so monitoring more often was not required. The DON stated the count was important to ensure a drug diversion did not occur. Review of the facility's policy Controlled Substances not dated, reflected the following: .8. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift 12. At the end of each shift: a. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. 676189 Page 6 of 12 676189 09/14/2023 The Legacy at Willow Bend 6101 Ohio Ste 500 Plano, TX 75024

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, interview, and record review, the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for the facility's only medication room and 1 (5300 hall nurses' medication cart) of 3 medication carts reviewed for pharmacy services in that: The facility failed to ensure: 1A vial of TB ( Tuberculosis ) serum that was opened and used was dated in the medication room refrigerator. 2The 5300 Hall medication cart had insulin pen for Resident #13 without an opened date. These failures could affect residents and staff resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications The findings include: 1-Observation on 09/12/2023 at 2:47 PM of the medication room revealed a vial of TB PPD (purified protein derivative) serum was opened, had been used and was not dated. Interview on 09/12/23 at 2:47 PM, LVN L stated the TB PPD vial was open and the rubber seal breached and was not dated or initialed. He said the risk when given to staff or resident could be the wrong reading. He stated the nurse was responsible to check the vial for the open date before use it. Interview on 09/12/23 at 3:20 PM, the DON said labeling of medications followed manufacturer instructions unless otherwise specifically indicated. She said the staff who opened the vial should have written the open date and the initials. She said all nurses were responsible to check the medication carts and the medication rooms for expiration and labeling of medication. 2- Record review of Resident #13's Comprehensive MDS, dated [DATE], revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, chronic kidney disease, and hyperlipidemia (too many lipids and fats in the blood). He had a BIMS of 15 indicating he was cognitively intact. Record review of Resident #13's physician's orders dated September 2023 revealed an order for insulin glargine solution 100 unit/ml. Inject 10 unit subcutaneously one time a day for diabetes, with an order date of 08/18/23 and no end date. Observation on 09/12/2023 at 3:10 PM revealed the 5300-hall nurse's medication cart had a pen of 676189 Page 7 of 12 676189 09/14/2023 The Legacy at Willow Bend 6101 Ohio Ste 500 Plano, TX 75024

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some insulin glargine solution 100 unit/ml for Resident #13. Observation revealed the used insulin pen did not have an opened date. Interview on 09/12/2023 at 3:15 PM, LVN K stated the glargine solution 100 unit/ml belonged to Resident #13 and did not have an opened date. LVN K stated she did not open the pen and she forgot to check if there was an open date on the pen. LVN K stated the purpose for putting an open date was for expiration purposes because the insulin was only good for 28 days. Interview on 09/12/23 at 3:20 PM, the DON stated the insulin flex pens, once opened, needed to be dated because each insulin pen had a 30 or 40-day shelf life and if not thrown out before that time, the insulin could lose its effectiveness. Record review of the facility's policy titled Administering Medications, not dated, revealed in part .12. The expiration /beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container . 676189 Page 8 of 12 676189 09/14/2023 The Legacy at Willow Bend 6101 Ohio Ste 500 Plano, TX 75024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure Dietary Cooks H and I washed hands during lunch meal preparation on 09/13/23. 2.The facility failed to ensure four of six trash cans in the kitchen were covered. These failures could place residents at risk for food contamination and food-borne illness. Findings included: 1. Observation on 09/13/23 at 12:09 PM revealed Dietary [NAME] H touched the metal shelf of steam table with her left open gloved hand. Dietary [NAME] H did not wash her hands. Dietary [NAME] H touched inside of the bowl and scooped food into bowl. She started scooping food on plate with utensil and touched the plates. At 12:28 PM Dietary [NAME] H changed gloves and did not wash hands before putting on new gloves. Observation on 09/13/23 at 12:12 PM revealed Dietary [NAME] I touched her left hand on her face with gloved hands. She put meat on stove. She changed gloves but did not wash hands between glove change. She took up fries with same gloved hands. At 12:18 PM, Dietary [NAME] I took gloves off and put new gloves on. She did not wash her hands between glove changes. She grabbed salad from bowl with her gloved hands. Interview on 09/13/23 at 12:35 PM with Dietary [NAME] H revealed she should have washed her hands when changing her gloves. She stated she should change her gloves and wash hands when her gloves get contaminated or soiled. Interview on 09/13/23 at 12:37 PM with Dietary [NAME] I stated she should have washed her hands between glove changes before putting on the new gloves. 2. Observations on 09/13/23 at 12:07 PM and 12:30 PM revealed four trash cans were not covered. Two trash cans, when entering kitchen, had no cover and contained used gloves and one of the trash cans had boxes on top. Two trash cans in food prep area revealed the lids were not over the trash can and had about ¾ full of food debris and used gloves in the food prep area were near the steam table. Interview on 09/13/23 at 12:38 PM with the Dietary Manager stated the dietary staff should have washed hands when changing gloves before putting on new gloves and when gloves were contaminated or soiled. He stated there was a recent in-service on hand hygiene about washing hands. He stated he would initiate an in-service on hand washing for all dietary staff today. Dietary Manager stated he was aware of two of the trash can lids not working to cover the trash can. He stated he needed new lids for these trash cans. He stated the other two trash cans did not have lids but he tried not to keep food debris in it. He stated he was aware the kitchen trash cans need to be covered but he would need to order kitchen trash cans that have a lid to keep the trash covered in the kitchen. 676189 Page 9 of 12 676189 09/14/2023 The Legacy at Willow Bend 6101 Ohio Ste 500 Plano, TX 75024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 09/13/23 at 1:55 PM with Dietary Manager stated the risk for dietary staff for not washing their hands place residents at risk for cross contamination and getting sick. He stated he expected dietary staff to wash hands when they become contaminated and when changing gloves to wash hands prior to putting on new gloves. Review of facility's in-service for dietary staff dated 02/24/23 by Dietary Manager reflected Dietary [NAME] I was in-serviced on hand washing practice. Review of facility's in-service on infection control and handwashing dated 09/07/23 reflected Dietary [NAME] H and I were in-serviced along with other facility staff. Review of facility's policy Proper/Adequate Hand Washing revised March 2011 reflected 1. Nutrition Services employees will keep their hands and exposed portions of their arms with soap in the handwashing sink. 5. Employees will wash their hands and exposed parts of their arms at the following times: a. After touching bare body parts (such as face, hair, etc.) other than clean hands and clean exposed arms .g. During food preparation, as often as necessary to remove soil and contamination when changing tasks i)After engaging in other activities that contaminate the hands. Review of facility's policy Garbage and Rubbish Disposal revised March 2011 reflected Garbage and rubbish will be disposed of in compliance with state and local regulations .2. All containers will have tight fitting lids or covers and such containers must be kept covered when stored or not in continuous use. 676189 Page 10 of 12 676189 09/14/2023 The Legacy at Willow Bend 6101 Ohio Ste 500 Plano, TX 75024

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 observation, interview, and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 (Resident #22, Resident #40) of 5 residents reviewed for infection control. Residents Affected - Few The facility failed to ensure CMA M disinfected the blood pressure cuff in between blood pressure checks for Residents #22 and #40. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Record review of Resident #22's Comprehensive MDS assessment, dated 08/13/23, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses including elevated blood pressure, congestive heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should), and type 1 diabetes mellitus. She was unable to complete the interview to determine the BIMS due to cognition issues. Record review of Resident #22's physician orders dated 09/14/23 reflected, metoprolol succinate extended release 25 mg tablet, give 0.5 tablet by mouth one time daily - Special instruction: Hold for heart rate less than 60. Record review of Resident #40's Comprehensive MDS, dated [DATE], revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease (a build-up of cholesterol plaque in the walls of arteries causing obstruction of blood flow), elevated blood pressure, and dementia. He had a BIMS of 14 indicating he was cognitively intact. Record review of Resident #40's physician orders dated 09/14/23 reflected, diuretics- monitor for the following: decreased PO (oral intake), acute confusion, agitation, delusions, hypotension and orthostasis (normal response of the body to counteract a fall in blood pressure when a person is laying down and assumes the upright position.) Observation on 09/13/23 at 8:06 AM revealed CMA M performing morning medication pass, during which time she checked the blood pressures on Resident #22. CMA M did not sanitize the blood pressure cuff before or after using it on Resident #22. Observation on 09/13/23 at 8:14 AM revealed CMA M performing morning medication pass, during which time she checked the blood pressure on Resident #40. CMA M used the same blood pressure cuff right after using it on Resident#22. CMA M did not sanitize the blood pressure cuff before using it on Resident #40. Interview on 01/13/23 at 8:28 AM, CMA M stated reusable equipment, like blood pressure cuffs, should be sanitized with wipes between each resident use (before and after use on each resident) in order to prevent transmitting an infection from one resident to another. She stated she forgot to wipe the cuff. 676189 Page 11 of 12 676189 09/14/2023 The Legacy at Willow Bend 6101 Ohio Ste 500 Plano, TX 75024

F 0880 Level of Harm - Minimal harm or potential for actual harm Interview on 09/14/23 at 1:30 PM, the DON stated that her expectation was that staff would sanitize all reusable equipment between each resident use. She stated that not doing so placed residents at risk of cross contamination of infections from one resident to another. She said she was responsible for training staff on infection control. She said that she did routine rounds in the floor to ensure the nurses and med aids were following proper infection control procedures. Residents Affected - Few Record review of facility's policy Cleaning and Disinfection of Resident -Care Items and Equipment, not dated, reflected . d. Reusable items are cleaned and disinfected or sterilized between residents. 3. Durable medical equipment must be cleaned and disinfected before reuse by another resident. 4. Reusable resident care equipment will be decontaminated and/or sterilized between residents according . 676189 Page 12 of 12