Legacy Nursing and Rehabilitation of Franklin

In the surveyor’s words

From the most serious findings on record at Legacy Nursing and Rehabilitation of Franklin, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Aug 9, 2024

  Based on interviews and record reviews, the facility failed to ensure nursing staff communicated a significant change in condition to the resident's physician and responsible party in a timely manner for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) residents reviewed for notification of change. This deficient practice resulted in an Immediate Jeopardy situation on 07/12/2024 at 6:08 p.m. for Resident #1, when Resident #1 was unable to adequately eat or drink and Resident #1's physician and responsible party were not notified. This deficient practice continued on 07/13/2024 when Resident #1 was unable to adequately eat or drink and Resident #1's responsible party was not notified. […]

• Immediate jeopardy, isolatedF692Aug 9, 2024

  Based on interviews and record reviews, the facility failed to maintain acceptable parameters of nutritional status/electrolyte balance for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) reviewed for nutritional status as evidence by: 1. Failing to ensure staff followed-up on and/or implemented a dietitian's recommendation (Resident #1); and, 2. Failing to ensure staff assisted a resident with maintaining their food and/or fluid intake to suit their dietary needs (Resident #1). This deficient practice resulted in an Immediate Jeopardy situation on 07/12/2024 at 6:08 p.m. for Resident #1 when Resident #1 was unable to adequately eat or drink and no adjustments were made to suit Resident #1's dietary needs. […]

• Immediate jeopardy, isolatedF835Aug 9, 2024

  Based on interviews and record reviews the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to implement a system to provide quality care to meet the needs of each resident by failing to: 1. Ensure staff communicated a resident's change in condition in a timely manner to the physician and responsible party for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) residents reviewed for notification of change; 2. Ensure staff followed-up on and/or implemented a dietician's recommendation for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) residents reviewed for nutritional status; and, 3. […]

• Actual harm, isolatedF689Dec 8, 2021

  Based on interviews and record reviews, the facility failed to ensure 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents reviewed for falls were free from accident hazards by staff failing to implement safe transfer techniques to reduce the risk of a fall. This deficient practice resulted in an actual harm for Resident #1 on 10/09/2021, when Resident #1 fell on the floor while being transferred from the wheelchair to the resident's bed by the Certified Nursing Assistant (CNA) staff. After the CNA staff picked Resident #1 up off the floor and placed the resident in bed, the CNA staff heard the resident saying Ouch. […]

• No harm, potential for more than minimal, patternF550Jan 7, 2026

  Based on observations, interviews, and record reviews, the facility failed to protect a resident's right to privacy for 1 (Resident #49) of 4 residents investigated for resident's rights. Findings:Review of the facility's undated Resident Right's and Quality of Life Policy and Procedure revealed, in part, all residents had the right to a dignified existence. Further review revealed residents were to be treated with consideration of his/her dignity, including privacy in treatment and care for his/her personal needs. Review of Resident #49's Minimum Data Set with an Assessment Reference Date of 11/13/2025 revealed Resident #49 had a Brief Interview Mental Status score of 15, which indicated Resident #49 was cognitively intact. […]