Health inspection·August 29, 2024

F 0812 - 1 large bag of approximately 40 carrots. There was no used by date or expiration date. Level of Harm - Minimal harm or potential for actual harm -1 small pan of an unidentified meat with a used by date 8/28/25. There was no label of item description. - 1 medium bowl of an unidentified meat. There was no used by date or label of item description. Residents Affected - Some - 1 lbs of roast beef exposed to air. There was no used by date or expiration date. An Interview on 08/27/24 at 10:15am the Dietary Manager who stated molded items and items that are past the use by or expired by date are thrown away. The expired and molded items were presented to the DM. The DM removed the molded and expired items and had staff discard the items at that time. Observations of the Dry Storage Room on 08/27/24 at 10:28 AM revealed the following: -1 2lbs bag of crisp rice cereal with best used by date of 08/09/24. -1 2lbs bag of crisp rice cereal with best used by date 06/09/24. - 1 2lbs corned flakes cereal with best used by date 02/03/2024. -1 large plastic bin of breadcrumbs dated restocked 4/24/24. There was no used by or expiration date. - 1 large plastic bin of flour dated restocked 5/1/24. There was no used by or expiration date. -1 larger plastic bin of corn starch dated restocked 4/30/24. There was no used by or expiration date. - 2 boxes with ten brown bananas. There was no used by or expiration date. -1 large box of approximately 25 potatoes. There was no used by or expiration date. - 1 large bag of approximately 20 onions. There was no used by or expiration date. -1 25 lbs. long grain parboiled rice was opened. There was no used by or expiration date. - (2) 4.5lbs boxes of black tea dated best by 05/12/24 and 06/29/24. An interview on 08/28/24 at 9:27am the Dietary Manager who stated the dates on items are the arrival date or opened date. DM stated items without manufacturers dates are dated with the received date. The DM stated if items are opened without a manufactured date, the items are discarded three days from the received date. DM stated flour, breadcrumb, and cornstarch are frequently used. The DM stated those items are restocked every 1-3 months. The DM stated flour, breadcrumb, and cornstarch usually has a shelf life of one year. Review of the facility's Food Receiving and Storage Policy dated March 2001: Revision November 2022, reflected Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: Dry Food Storage: 4. Dry foods (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676489 If continuation sheet Page 2 of 3 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 08/29/2024 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 Residents Affected - Some that are stored in bins will be removed from original packaging, labeled, and dated (use by date). Such foods will be rotated using a first in - first out system. Refrigerated/Frozen Storage 1. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). 7. Refrigerated foods are labeled, dated, and monitored so they are used by their use by date, frozen, or discarded. 8. Frozen foods are maintained at a temperature to keep the food frozen solid. Wrappers of frozen foods must stay intact until thawing. Review of the U.S. FDA Food Code 2022 reflected: Chapter 3 . section 3-201.11 Compliance and Food Law: . C. Packaged Food shall be labeled as specified in Law, including 21 CFR 101 Food Labeling [* .(b) A food which is subject to the requirements of section 403(k) of the act shall bear labeling, even though such food is not in package form. (c) A statement of artificial flavoring, artificial coloring, or chemical preservative shall be placed on the food or on its container or wrapper, or on any two or all three of these, as may be necessary to render such statement likely to be read by the ordinary person under customary conditions of purchase and use of such food. The specific artificial color used in a food shall be identified on the labeling when so required by regulation in part 74 of this chapter to assure safe conditions of use for the color additive.], 9 CFR 317 Labeling, [*(a) When, in an official establishment, any inspected and passed product is placed in any receptacle or covering constituting an immediate container, there shall be affixed to such container a label .Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under § 3-202.18. Section 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. Section 3-501.17 . Commercial processed food: Open and hold cold . B. 1. The day the original container is opened in the food establishment shall be counted as Day 1. 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. C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section. Definitions 3. Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated. www.fda.gov an *- www.ecfr.gov FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676489 If continuation sheet Page 3 of 3