Legacy Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Legacy Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Dec 2, 2022

  Based on observation, record review, and interview, the facility failed to ensure the resident environment was as free of accident fire hazards as possible, as evidenced by failure to immediately remove electrical power strips and extension cords that were improperly used in the facility before and after an incident where a power strip malfunctioned. This failed practice resulted in noncompliance at the level of Immediate Jeopardy that had the potential to cause serious injury, harm, or death to all 94 residents residing in the facility according to a Resident Census List provided by the Director of Nursing (DON) on 12/1/22. The Administrator was informed of the Immediate Jeopardy condition on 12/1/22 at 5:25 PM. The findings are: 1. […]

• Immediate jeopardy, isolatedF689Dec 16, 2022

  Based on record review and interview the facility failed to ensure Care Plan interventions were in place to prevent a fall for 1 (Resident #1) of 1 (R #1) sampled resident. The failed practice resulted in past non-compliance at the level of Immediate Jeopardy, which caused or could have caused serious harm, injury, or death for Resident #1, who was at risk for falls and was left without the bed alarm that was Care Planned. This failed practice had the potential to cause more than minimal harm to 1 resident who was at risk for falls and had a fall that resulted in an ankle fracture as documented on a list provided by the Medical Records Clerk on 12/16/22. The Administrator was informed of the past immediate jeopardy condition on 12/15/22 at 12:21 PM. The Findings are: 1. […]

• Immediate jeopardy, isolatedF697Oct 12, 2022

  Based on record review and interview the facility failed to ensure pain management consistent with professional standards of practice was provided for one resident (resident #1) of six (R#1, R#2, R#3, R#4, R#5, R#6) residents reviewed who were admitted with Physician Orders for pain medication. This failed practice had the potential to affect 1 resident who was at risk of pain due to fracture and resulted in past immediate jeopardy that caused or was likely to cause serious harm, injury, or death to Resident #1. The Administrator, Director of Nursing (DON) and the Consultant were notified of the Past Immediate Jeopardy (IJ) on 10/12/22 at 9:38 AM. […]

• Immediate jeopardy, isolatedF689Oct 1, 2021

  Based on observation, record review and interview, the facility failed to ensure a resident who was at risk for elopement and was actively exhibiting exit-seeking behaviors was redirected in accordance with the plan of care to prevent elopement, when staff observed the resident heading toward the front of the facility unattended for 1 (Resident #1) of 3 (Residents #1, #2 and #3) sampled residents who had exit-seeking behaviors. The failed practice resulted in past noncompliance at the level of immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who exited the facility undetected by staff, and had the potential to cause more than minimal harm to 9 residents who were at risk for elopement, as documented on a list provided by the Administrator… […]

• No harm, potential for more than minimal, widespreadF812Dec 30, 2022

  Based on observation and interview, the facility failed to ensure food items stored in the freezer were covered, sealed, and dated; kitchen vents were cleaned to provide a sanitary environment for food preparation; floors, dish washer, kitchen walls, door frames and baseboards were free of rotten wood; chipped floor tiles were free of debris, dirt, grease, grime, rust, stains, and spills; ceiling tiles were replaced and in a sanitary condition; and dietary staff washed their hands before they handled clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. […]