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Complaint Investigation

Legend Healthcare And Rehabilitation - Greenville

August 28, 2025 · Greenville, TX · 2300 Jack Finney Blvd
Citations 2
CMS Rating 3/5
Beds 126
Provider ID 675774
Healthcare Facility
Legend Healthcare And Rehabilitation - Greenville
Greenville, TX  ·  View full profile →
Inspection Summary

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.

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Inspection Findings

FF0755
Pharmacy Service Deficiencies
Potential for More Than Minimal Harm

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.

Facility ID:

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.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in GREENVILLE, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LEGEND HEALTHCARE AND REHABILITATION - GREENVILLE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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