Health inspection·February 20, 2025

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record reviews, the facility failed to ensure that each resident had a right to personal privacy and confidentiality of his or her own personal medical records for 1 (Resident #94) of 2 residents investigated for privacy of medical records. Residents Affected - Few The facility failed to ensure when Resident #93 discharged from the facility Resident #94's Personal Private Information was not handed to Resident #93's Resident's representative. This failure could place residents at risk of having medical information exposed to others and possible misuse of personal information. Findings included: Review of an attachment to the complaint intake revealed two pictures of a document that was discerned to be Resident #94's Face Sheet which contained Resident #94's name, birthdate, social security number and all diagnosis. In an interview on 02/14/2025 at 10:21 AM with the resident representative for Resident #93 the resident representative stated that she had been at the facility to assist with the discharge of Resident #93 when she was handed Resident #93's medical/personal records by an unknown staff member. She stated it was not until a few days later that she discovered that the facility had also included Resident #94's face sheet. In an interview on 02/20/2025 at 2:12 PM , the DON stated after reviewing the pictures of the documents in the possession of Resident #93's resident representative that the documents were the Face Sheet for Resident #94. She stated that the incident must have happened two years ago, but that all staff should always be aware of protecting resident information. She stated that they have not had any other similar incidents in the past 12 months that she had been working as the DON at the facility. She stated it was important to protect resident private/medical information or residents could be at risk of psychological or financial harm. Record Review of facility provided policy, Labeled, Protected Health Information (PHI) Management and Protection, date Revised on April 2023, stated: Policy Statement: Protected Health Information (PHI) shall not be used or disclosed except as permitted by current federal and state laws. Policy Interpretation and Implementation: Page 1 of 6 676413 676413 02/20/2025 Legend Oaks Healthcare and Rehabilitation Garland 2625 Belt Line Road Garland, TX 75044

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1. It is the responsibility of all personnel who have access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release or disclosure. online website, at: http://www.hhs.texas.gov/regulations/legal-information/hipaa-privacy-laws, date not listed. Stated: Privacy Rule: The HIPAA privacy rule establishes national standards protecting medical records and other personal health information. 676413 Page 2 of 6 676413 02/20/2025 Legend Oaks Healthcare and Rehabilitation Garland 2625 Belt Line Road Garland, TX 75044

F 0759 Ensure medication error rates are not 5 percent or greater. 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 that the medication error rate was not five percent or greater. The facility had a medication error rate of 13.33% based on four errors out of 30 opportunities, which involved three (Resident #28, Resident #74, and Resident #89) of six residents reviewed for medication errors. Residents Affected - Some 1. The facility failed to ensure Resident #28's Glipizide (lowered blood sugar) and Benzonatate (treats cough) was administered as ordered during the scheduled timeframe of 7:00 a.m. to 10:00 a.m. 2. The facility failed to ensure Resident #74's Carvedilol (treats high blood pressure) was administered as ordered during the scheduled timeframe of 7:00 a.m. to 10:00a.m. 3. The facility failed to ensure Resident #89's Metformin (lowers blood sugar) was administered as ordered during the scheduled timeframe of 7:00 a.m. to 10:00a.m. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or not receiving them as prescribed, per physician orders. Findings included: 1. Record review of Resident #28's Quarterly MDS dated [DATE] revealed Resident #28 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of diabetes and chronic respiratory failure. The MDS also revealed the BIMS score was 15 (no cognitive impairment). Record review of Resident #28's care plan with a revision date of 11/22/2024 revealed Resident #28 had diabetes that was managed with oral medication and included interventions such as administering medications as ordered. The care plan also revealed Resident #28 had chronic respiratory failure and included interventions such as administering medications as ordered. Record review of Resident #28's physician order dated 3/11/2024 revealed Resident #28 was to receive one tablet of glipizide 5mg two times a day. The order indicated doses were scheduled between 7:00 a.m. to 10:00 a.m. and 2:00 p.m. to 6:00 p.m. Record review of Resident #28's physician order dated 2/03/2025 revealed Resident #28 was to receive one capsule of Benzonatate 200mg three times a day. The order indicated doses were scheduled between 7:00 a.m. to 10:00 a.m., 12:00 p.m. to 2:00 p.m., and 4:00 p.m. to 8:00 p.m. In an observation on 2/18/2025 at 11:27 a.m., MA A administered eight medications to Resident #28 including Glipizide and Benzonatate that was ordered to be administered between 7:00 a.m. to 10:00 676413 Page 3 of 6 676413 02/20/2025 Legend Oaks Healthcare and Rehabilitation Garland 2625 Belt Line Road Garland, TX 75044

F 0759 a.m. The glipizide and Benzonatate on the MAR was red on the computer screen. Level of Harm - Minimal harm or potential for actual harm 2. Residents Affected - Some Record review of Resident #74's Annual MDS dated [DATE] revealed Resident #74 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of hypertension (high blood pressure) and coronary artery disease (heart disease). The MDS also revealed a BIMS score of 07 (suggested severe cognitive impairment). Record review of Resident #74's care plan with a revision date of 12/23/2024 revealed Resident #74 had an altered cardiovascular status related to hypertension and the goal was to remain free from cardiac complications. Record review of Resident #74's physician order dated 1/13/2025 revealed Resident #74 was to receive one tablet of carvedilol 6.25mg two times a day. The order indicated doses were scheduled between 7:00 a.m. to 10:00 a.m. and 2:00 p.m. to 6:00 p.m. In an observation on 2/18/2025 at 11:47 a.m., MA A administered 11 medications to Resident #74 including carvedilol that was ordered to be administered between 7:00 a.m. to 10:00 a.m. The carvedilol on the MAR was red on the computer screen. 3. Record review of Resident #89's Comprehensive MDS dated [DATE] revealed Resident #89 was a [AGE] year-old male that was admitted to the facility on [DATE] with a diagnosis of diabetes. The MDS also revealed a BIMS score of 09 (suggested moderate cognitive impairment). Record review of Resident #89's care plan with a revision date of 1/27/2025 revealed Resident #89 had diabetes and included interventions such as administering medications as ordered. Record review of Resident #89's physician order dated 2/10/2025 revealed Resident #89 was to receive one tablet of Metformin 850mg two times a day. The order indicated doses were scheduled between 7:00 a.m. to 10:00 a.m. and 2:00 p.m. to 6:00 p.m. In an observation on 2/18/2025 at 12:13 p.m., MA A administered eight medications to Resident #89 including Metformin that was ordered to be administered between 7:00 a.m. to 10:00 a.m. The Metformin on the MAR was red on the computer screen. In an interview on 2/19/2025 at 12:32 p.m., MA A stated that he administered medications as scheduled on the MAR and that the medications on the MAR turned red when late. MA A stated he tried to make sure medications were administered during those times. MA A stated it was not right to give those medications too close together. In an interview on 2/20/2025 at 10:05 a.m., MA A stated he did not intentionally give medications late to Resident #28, Resident #74, and Resident #89 on 2/18/2025. MA A stated he was running behind and that did not usually happen. MA A stated he was not sure what the risks to the residents were but that he would not like it if he did not get his medications correctly. In an interview on 2/19/2025 at 12:36 p.m., ADON B stated there was a window on the MAR that 676413 Page 4 of 6 676413 02/20/2025 Legend Oaks Healthcare and Rehabilitation Garland 2625 Belt Line Road Garland, TX 75044

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indicated medications should have been given between 7:00 a.m. and 10:00 a.m. ADON B stated the medications should be given between those times or the doctor should be called to change the time. ADON B stated that it was possible that if medications were given late that it could affect the resident. Clinical Resource Nurse C was in the room and stated she was responsible for checking the MARs once a week when she was in the building. Clinical Resource Nurse C stated the risk to the residents was that they could experience health problems and the expectation was that medications were administered on time. In an interview on 2/19/2025 at 12:48 p.m., the DON stated staff that administered medications should give medications within the window scheduled. The DON stated the staff had an hour before and an hour after the scheduled times to administer the medications. The DON stated the risks to the residents were that the medications could be given too close together or lead to an adverse event. The DON reported that the nurse management team was responsible for monitoring that medications were administered correctly. In an interview on 2/20/2025 at 1:05 p.m., the MD stated that the medications that were administered late on 2/18/2025 would not cause harm but that he would like them to be administered spaced out. The MD stated his expectation was that the medications were ideally administered as ordered within the window they were scheduled. In an interview on 2/20/2025 at 12:30 p.m., the medication administration and medication error policies were requested from the DON. At the time of exit, the medication error policy was not received. Review of facility policy titled, Medication Administration, with a revision date of 07/2015, revealed It is the policy of this facility that medications shall be administered as prescribed by the attending physician. 676413 Page 5 of 6 676413 02/20/2025 Legend Oaks Healthcare and Rehabilitation Garland 2625 Belt Line Road Garland, TX 75044

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for food safety in the facility's only kitchen. Residents Affected - Some The facility failed to ensure that food items past there expiration date were discarded. This failure could place residents at risk of exposure to food borne illnesses. Findings included: In an observation and interview on 02/18/2025 at 9:41 AM two 48-ounce plastic jars of opened Spaghetti Sauce were observed on a shelf in the walk-in refrigerator in the kitchen of the facility. Both jars were found to have no dates of when they were opened or a discard date. The Dietary Manager stated all food in the walk-in refrigerator should have an open and discard date. She stated foods that are past their discard dates could become spoiled and possibly expose residents to possible food-related illness. She stated because there were no dates on the containers, she was unable to determine when they were opened or when they should be discarded. In an interview on 2/18/2025 at 10:09 AM [NAME] F revealed that it was important to make sure all leftover foods in the refrigerator have an opened and discard date. She stated that it could make residents ill if they are exposed to possibly spoiled foods. She stated that she had received training on how to properly store foods. Record review of all dietary aides and Cooks food safety certificates found that all certificates were up to date. In an interview on 2/20/2025 at 2:32 PM the DON revealed that if residents ingested spoiled foods or foods that were past their respective discard dates it could cause food-borne illnesses or discomfort to residents. Review of the facility's policy Frozen and Refrigerated Foods Storage, revised November 2017, reflected, 9. Items stored in the refrigerator must be dated upon receipts, unless they contain a manufacturer use by, sell by, best by date, or a date delivered . The Food and Drug Administration Food Code dated 2017 reflected, 3-305.11 Food Storage (B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . Date marking is the mechanism by which the Food Code requires active managerial control of the temperature and time combinations for cold holding. Industry must implement a system of identifying the date or day by which the food must be consumed, sold, or discarded. 676413 Page 6 of 6