Legend Healthcare And Rehabilitation - Greenville
LEGEND HEALTHCARE AND REHABILITATION - GREENVILLE in GREENVILLE, TX — inspection on August 28, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of facility's policy Administration of Drugs revised May 2021 reflected .3.
All current drugs and dosage schedules must be recorded on the resident's electronic administration record (eMAR).6.
When PRN medications are administered, the nurse must record: A.
Justification/reason the medication is given B.
The date and time administered via eMAR C.
Any results achieved from administering the drug and the time each results were observed.Right documentation - Document administration or refusal of the medication after the administration or attempt and note any concerns.
Review of the facility's policy Controlled Medications - Storage and Reconciliation revised January 2022, reflected, . A reconciliation or physical inventory of all controlled medications is conducted by two licensed nurses and is documented on an audit record at each shift change.
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IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/28/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Legend Healthcare and Rehabilitation - Greenville
2300 Jack Finney Blvd Greenville, TX 75402
SUMMARY STATEMENT OF DEFICIENCIES
Based on observations, interviews, and record review, the facility failed to ensure that drugs and biologicals were stored properly in locked compartments for one of five medication carts (medication cart for hall 300) reviewed for storage of Drugs and Biologicals.
The facility failed to ensure RN F locked his medication cart for hall 300 on 08/27/2025.
This failure could place the residents at risk of accessing/opening the cart causing accidental overdose or misuse of medications and not receiving the full benefit of the medication.
Findings included: Observation on 08/27/2025 at 03:44 p.m. revealed a medication cart was parked against the wall with the drawers facing out toward the hallway.
The cart was not locked because the centralized, metal, round lock, was protruding and the metal lock needed to be pushed in to lock the drawers of the cart.
The cart was facing the hallway, and the drawers could easily be opened.
The drawers of the cart contained various over-the-counter medications, blister packs of medications, and insulins.
Several staff and residents were passing by the unlocked cart.
Approximately 5 minutes passed when RN F walked out of a Resident #100's room and returned to the medication cart. In an interview with RN F on 08/27/25 at 03:50 p.m. he stated he forgot to push the button on the cart to lock it before he answered the Resident #100's call light.
He stated the risk of leaving the cart unlocked was anyone could have accessed the medications in the cart. He said the cart should be locked every time it was left unattended because anybody, residents, staff, and visitors, could open it and could get anything from the cart. In an interview with the DON on 08/28/2025 at 11:10 a.m., she stated medication carts should be always locked to prevent unauthorized access to the medications.
She stated the risk were to resident's obtaining medications that was not intended for them as well as diversion of medications.
She stated RN F was an as needed employee, but stated she had never seen him leave the cart unlocked.
She stated they would re-educate him on the importance of keeping the medication cart secured.
Record review of facility policy Medication Storage , revised May 2021 reflected, It is the policy of this facility to ensure the proper and safe storage of drugs and biologicals.Drugs and/or biologicals should not be left unsecured/unattended.Medication and treatment carts will be kept locked when unattended.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.