Legacy Nursing and Rehabilitation of Pollock

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jul 19, 2023

  Based on observation, interview and record review the facility failed to increase supervision of residents at risk for elopement and respond to alarms appropriately, for 2 (Resident #1 and Resident #2) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents for elopement. The facility failed to: 1. Ensure door exit alarms could be heard by all staff in residents' rooms when the doors are closed; 2. Ensure a system of staff response was in place when the door alarm sounded, and staff were knowledgeable of the response system; and 3. […]

• Immediate jeopardy, isolatedF835Jul 19, 2023

  Based on interview and record review the failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 2 residents (#1 and #2) in a sample of 5 residents (#1, #2, #3, #4 and #5) reviewed for elopement. The facility's Administration failed to: 1. Ensure supervision was increased for residents at risk for elopement when staff became aware of improper functioning of door alarms and doors; 2. Ensure an effective system of staff response was in place when the door alarm sounded; and 3. Ensure staff were effectively trained and knowledgeable of their system of response, and adhered to training. […]

• No harm, potential for more than minimal, patternF677Oct 1, 2025

  Based on interview and record review, the facility failed to ensure Residents who are unable to carry out ADLS (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene for 3 (#10, #56, #67) of 4( #10, #56, #67, and #90) Residents reviewed for ADLS. The facility failed to ensure Resident #67 received a bath on his scheduled bath day, and failed to ensure Residents #10 and #56 received appropriate nail care. The total sample size was 37. Findings: Review of the facility's undated policy titled: Nail Care Policy and Procedure read in part.Procedure: (1) care of fingernails and toenails is part of the bath. (2) be certain nails are clean. (4) nails are to be clipped and filed smoothly. […]

• No harm, potential for more than minimal, patternF755Oct 1, 2025

  Based on observation, interview, and record review the facility failed to provide pharmaceutical services that assured accurate acquiring, receiving, dispensing and/or administration of medications to meet the needs of each resident. The facility had a total census of 86 residents. The facility failed to: 1. Ensure the on-coming nurse (S4 LPN) documented and signed the Narcotic count sheet at the beginning of shift; and 2. Ensure an accurate account for controlled substance medications were completed at the time of administration by S4 LPN on 1 (Cart A) of 2 (Cart A and Cart B) medication carts for Residents #1, #27, #40, #42, #51, #57, #62, #65, #72, #78, and #91.Findings: Review of an undated facility policy on 10/01/2025 at 11:36 a.m. […]

• No harm, potential for more than minimal, patternF880Oct 1, 2025

  Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections by failing to:1. Disinfect reusable medical equipment as required, 2. Maintain soiled linen/soiled items in a sanitary manner;2. Store clean linen in a sanitary manner; and3. Ensure staff were consistent with infection control practices for cleaning/disinfecting the environment. Findings: Review of an undated facility policy titled Infection Prevention and Control- Environmental Services read in part. […]