Legend Healthcare And Rehabilitation - Greenville

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

pain medication. He stated Resident #100 had complained of pain level of 5 or 6 so he administered Resident #100's prn pain medication as ordered. He stated it was important to document the prn pain medication so it would show how often they are getting the pain medication, to document the pain levels at time of administration and follow up to ensure effectiveness of pain medication. Interview on 08/28/2025 at 11:01 AM with the DON revealed she expected the charge nurse to document Resident #100's pain level, administer medication as ordered, document it on the MAR along with the narcotic count sheet. She stated not documenting on the MAR when giving a prn pain narcotic medication could place residents at risk of medication given outside of physician orders and possible drug diversion if not documented accurately. She stated the charge nurse should document if getting the narcotic pain medication out of emergency kit in resident's chart. Surveyor attempted to contact RN F on 08/28/2025 at 12:08 PM, but was unable to reach RN F. Interview on 08/28/2025 at 12:09 PM with RN B revealed she could not recall what night she worked with Resident #100 but Resident #100 requested her prn pain medication for pain. She stated she did give

the hydrocodone-acetaminophen 10-3325 2 tablets to her as ordered and documented on the narcotic count sheet. She stated she must have forgotten to document it on Resident #100's MAR to show the pain level and signing it was given. She stated she usually did document in the MAR when giving prn scheduling pain medication. 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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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Legend Healthcare and Rehabilitation - Greenville

2300 Jack Finney Blvd Greenville, TX 75402

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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

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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