Health inspection·July 20, 2023

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few anything that needed correction/refresher. R.N. C stated it was never okay to leave medications on top of the medication cart unattended. R.N. stated medications left unattended put residents/others at risk for taking substances not prescribed for them and could cause serious illness or death. Interview on 7/20/23 at 11:59 AM, the DON stated medications should never be left unattended. The DON stated she had been in her position such a short time that she had not had the opportunity to provide staff in-services; that was one of her responsibilities. The DON stated all nurses/MA's had been in-serviced on medication security since this incident. The DON stated leaving medications unsecured put residents/others at risk for illness. Interview on 7/20/23 at 12:06 PM, the facility Administrator stated the DON was responsible for in servicing all staff. The Administrator stated medications should always be secured and never left unattended. The Administrator stated unattended medications placed residents/others at risk of illness. Record review of the facility's, undated, current Standards and Guidelines, revealed the following: Storage of Drugs and Biologicals did not specifically address securing all medications inside medication carts. Record review of https://rcni.com/nursing-standard/opinion/expert-advice/medicines-management on 7/26/23 revealed All medicines should be locked away in a treatment room, drug trolley or the patient's bedside locker. Record Review of https://www.google.com/search?q=can+medications+be+left+on+med+cart+top&rlz=1C1GCEB_enUS969US971&oq=can+ 69i57.17052j0j1&sourceid=chrome&ie=UTF-8 on 7/26/23 revealed Medication carts should never be brought into resident rooms and should instead remain in the doorway with the outward side of the cart inaccessible to passersby. No medication should be kept on the top of the cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676489 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 676489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Legacy Midtown Park 8280 Manderville Lane Dallas, TX 75231 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 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, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. Residents Affected - Some 1. The facility failed to ensure food items were kept away from potential airborne contaminants (dust and fuzz) on the mixer, knife rack, piping leading to the ice machine, and utility shelving. 2. The facility failed to ensure food items were properly covered and labeled with the contents or date the items were placed in the refrigerator in accordance with professional standards. 3. The facility failed to ensure raw beef was stored away from prepared food in the walk-in refrigerator. These failures could place residents at risk for food contamination and food-borne illness. Findings include: Observation on 07/18/2023 at 9:15 AM in the facility's kitchen refrigerator revealed the following items were not labeled or dated with the date they were placed in the refrigerator: Rice pudding Peach cobbler Chocolate crumb cake Pecan Pie (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676489 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 676489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Legacy Midtown Park 8280 Manderville Lane Dallas, TX 75231 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 0812 Cake Level of Harm - Minimal harm or potential for actual harm In an interview on 07/18/2023 at 9:25 AM, the Kitchen Supervisor identified the rice pudding, peach cobbler, chocolate crumb cake, pecan pie, and cake. She said she was not sure when they were placed in the refrigerator. She stated the items should be labeled so all staff could identify the items and dated with the date they were placed in the refrigerator to ensure freshness and prevent possible food-borne illness. She said the [NAME] was responsible to ensure all food items were dated and labeled but was not sure which [NAME] placed the items into the refrigerator. An observation in the facility's walk-in refrigerator revealed a container of raw meat on the top shelf of a tray cart beside containers of prepared fruits and vegetables. The raw meat was covered but not labeled with the contents or the date it was placed there. Residents Affected - Some In an interview on 07/18/2023 at 9:25 AM, the Kitchen Supervisor stated the raw meat should not be on the same shelf as any prepared foods and should be stored on the bottom shelf to minimize the possibility of raw meat juices contaminating other foods. She stated this could cause food borne illness. She said she was not sure who placed the meat on the shelf. She asked the Cook, who denied doing it. The [NAME] told the Kitchen Supervisor she did not know who placed the raw meat on the shelf and did not know when it was placed there. An Observation on 07/19/2023 at 8:01 AM in the facility's kitchen revealed a large industrial mixer, in the food preparation area, with built up dust and grease on the top and sides, a utility rack with dust and fuzz on the shelving. The utility rack stored clean metal inserts and plate covers. An observation of the ice machine revealed a pipe leading to the filter, next to the opening of the ice machine to be covered with dust and fuzz. A magnetic knife holder attached to the backsplash of the food preparation area was also covered with dust and crumbs. In an interview on 07/19/2023 at 8:10 AM, the Kitchen Supervisor stated the kitchen was cleaned regularly by the dishwashers and a cleaning schedule was in place as a guide. She stated all kitchen equipment should be clean and free of any debris that could contaminate food during preparation. She said the Dietary Manager followed up with the cleaning schedule to ensure it was followed. She stated when the Dietary Manager was not working, it was the Cook's responsibility to follow up. In an interview on 07/19/2023 at 8:20 AM, the Dietary Manager said she expected staff to know food needed to be labeled and dated with the date the item was opened to ensure freshness and prevent the possibility of food born illness. She said the dishwashers were responsible for cleaning kitchen equipment according to the cleaning schedule. She provided a copy of the cleaning schedule. In an interview on 07/20/2023 at 8:05 AM, the Dishwasher stated there was a cleaning schedule for kitchen equipment, but she had been on vacation for three weeks. She said she did not know who was working while she was gone but assumed they would have been responsible for the cleaning during that time. She was unable to say when she last cleaned the mixer, ice machine filter pipe, utility shelf, or knife holder. She said she knew it was important to keep the items clean as dirt and dust could contaminate food items being prepared nearby. In an interview on 07/20/2023 at 9:15 AM, the Administrator said she expected the kitchen staff to follow all food safe handling procedures to prevent food contamination or food born illness. An observation and interview on 07/20/2023 at 8:00 AM with the Kitchen Supervisor revealed a pound cake in the refrigerator that was uncovered and undated. She stated the cake must have been opened (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676489 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 676489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Legacy Midtown Park 8280 Manderville Lane Dallas, TX 75231 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 0812 Level of Harm - Minimal harm or potential for actual harm last night but was not sure why it was not dated or labeled. She said whoever opend it should have labeled and deted the pound cake. Record review of the cleaning scheduled reflected the mixer was to be cleaned on Tuesdays by the morning Cooks and shelving on Saturdays by the morning cooks. Residents Affected - Some Record review of the facility's in-service records, titled Label, Dates, Temp Logs, dated 04/10/2023, reflected nine staff names which included the Kitchen Supervisor, Cook, and Dishwasher. The in-service reflected Why is it important to label and date food: This helps prevent foodborne disease outbreaks. This practice recommended in the Food and Drug Administration's (FDA) Food Code. They should be marked with a date indicating when the food should be eaten, sold, or thrown away. Record review of the facility's policy titled, Sanitation, dated October 2008 reflected, The food service area shall be maintained in a clean and sanitary manner. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary .Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food services staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. Record record review of the Federal Drug Administration Food Code dated 2022 section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils revealed (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 3-305.11 Food Storage. (A) Except as specified in (B) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) FOOD in packages and working containers may be stored less than 15 cm (6 inches) above the floor on case lot handling EQUIPMENT as specified under § 4-204.122. 3-305.14 Food Preparation. During preparation, UNPACKAGED FOOD shall be protected from environmental sources of contamination. 3-307.11 Miscellaneous Sources of Contamination. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. 3-501.17 - Commercially processed food Open and hold cold (B) Except as specified in (E) - (G) of this section, 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: Pf (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Pf 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676489 If continuation sheet Page 5 of 5