Legacy At Jacksonville

F 0656 Level of Harm - Minimal harm or potential for actual harm

objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet

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

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Legacy at Jacksonville

810 Bellaire St.

Jacksonville, TX 75766

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 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #1) reviewed for infection control. The facility failed to ensure CNA A and LVN B followed enhanced barrier precautions and wore a gown and gloves when providing incontinent care to Resident #1 on 11/10/2025. This failure could place residents at risk for cross contamination and infection.

Findings included: Record review of Resident # 1's facility face sheet revealed Resident #1 was a [AGE] year-old female and admitted on [DATE REDACTED] with diagnosis of encounter for gastrostomy (a tube placed in the stomach to assist with feeding). Record review of Resident 1's Quarterly MDS assessment dated [DATE REDACTED] revealed a BIMS score of 12 indicating intact cognition, relied on staff for all ADL's, was incontinent of bowel and bladder, and required a feeding tube. Record review of Resident #1's comprehensive care plan dated 10/08/2025 revealed Resident #1 required a feeding tube, but did not address EBP.Record review of Resident #1's consolidated orders revealed Resident #1 did not have an order for EBP.During an

observation on 11/10/2025 at 10:03 am, LVN B and CNA A entered Resident #1's room to reposition her and provide incontinent care. During care, it was observed that the resident had a feeding tube. Neither LVN B nor CNA A had applied PPE before providing care to Resident #1 who had a feeding tube in place. There was no sign on Resident #1's door indicating EBP was required. During an interview on 10/11/2025 at 10:19 am, CNA A said that if a resident needed EBP, there would be a sign on the door and PPE outside

the door. She said she provided care to Resident #1, and she did have a feeding tube and should be on EBP. She said she failed to put on PPE when she and the nurse gave care and by doing so infections could spread. During an interview on 10/11/2025 at 10:25 am, LVN B said that any resident that had a wound, feeding tube, or device like an intravenous catheter should be on EBP. She said she was not sure why Resident #1 did not have a sign and PPE outside her room, and she had forgotten when she and CNA A provided care. She said when residents were on EBP a gown and gloves must be worn with direct contact patient care. She said the ADON and the DON were responsible for putting out the signs and PPE, but she should have known. She said by not following EBP infections could spread.During an interview on 11/10/2025 at 10:31 am, the DON said she was the infection prevention nurse and she and the ADON were responsible for ensuring the residents that required EBP that those measures were in place. She said she overseen the staff to ensure they were following the program and Resident #1 had moved rooms and they failed to ensure the EBP sign, and PPE followed her. She said she expected that all staff followed the EBP program for all residents to prevent the spread of infections.During an interview on 11/10/2025 at 4:17 pm,

the Administrator said the DON was responsible for the infection control and EBP program in the facility.

She said there were clinical meetings every morning and EBP was discussed. She said the staff were notified verbally and there was a sign posted on the door as well to indicate EBP. She said she expected all staff to always follow the EBP program and if they were unsure, they needed to ask. She said if staff were not following EBP infections could happen. Record review of the facility's policy titled Enhanced Barrier Precautions dated 4/01/2024 indicated, .Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet