Legacy Nursing and Rehabilitation Winnsboro

In the surveyor’s words

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

• Actual harm, patternF690May 15, 2024

  Based on interviews, observations, and record reviews, the facility failed to ensure a resident admitted with a urinary catheter received necessary treatment and services, consistent with professional standards to promote healing and prevent infections for 1 (#9) of 3 (#9, #40, and #231) sampled residents reviewed for urinary catheters. This failed practice resulted in actual harm for resident #9 on 04/16/2024 due to the facility failing to: 1. Ensure resident #9 was free of urinary tract infections as evidenced by resident #9 having a urinary tract infection on 04/16/2024 and again on 05/13/2024, and was treated with antibiotic therapy on both occasions for 5 days, beginning respectively on 04/17/2024 and 05/13/2024. 2. […]

• Actual harm, isolatedF600Feb 15, 2024

  Based on observation, record review, and interviews, the facility failed to protect the residents' right to be free from physical and verbal abuse and psychosocial harm by staff for 1 (#7) of 4 (#1, #4, #5, and #7) sampled residents. The actual harm resulted for resident #7, who was cognitively impaired, on 02/13/2024 at approximately 1:12 p.m. when S3Certified Nursing Assistant (CNA) was witnessed being physically and verbally abusive to resident #7. S3CNA was witnessed by two Licensed Practical Nurses (LPNs) aggressively pull resident #7 up from her geri-chair and then popped her on the behind. S3CNA also was witnessed telling resident #7 to stop f______ pulling that sh__ down, I'm tired of the f______ sh__. […]

• Actual harm, isolatedF689Aug 17, 2023

  Based on record reviews and interviews, the facility failed to ensure that the resident received adequate supervision and assistance devices to prevent accidents for 1 (#1) of 5 (#1, #2, #3, #4, #5) sampled residents. The actual harm resulted for Resident #1 on 07/14/2023 when S4Certified Nursing Assistant (CNA) failed to use a two-person transfer, as determined necessary by the comprehensive care plan, during a transfer from the resident's wheelchair to bed. Resident #1 complained of pain and was sent to the local hospital. An x-ray of Resident #1's left hip showed comminuted displaced and angulated left hip and intertrochanteric fracture. Resident #1 was admitted to the hospital for management of her acute left hip fracture. […]

• Actual harm, isolatedF600Jan 11, 2023

  Based on observations, record review, and interviews, the facility failed to protect the resident's right to be free from sexual abuse and psychosocial harm by another resident for 1 (#1) of 5 (#1, #2, #3, #4, #5) sampled residents. The actual harm resulted when resident #1 had increased anxiety and nightmares, along with feeling ashamed after the 12/03/2022 sexual abuse incident. Resident #1 received a 12/08/2022 physician's order for a dosage increase to her antidepressant medication; and an order for an anti-anxiety medication was also added to her drug regime after the 12/03/2022 sexual abuse incident. The resident also had a 12/08/2022 physician's order for therapy and has been receiving individualized therapy every two weeks since the 12/03/2022 sexual abuse incident. […]

• No harm, potential for more than minimal, patternF584Jul 9, 2025

  Resident #74 On 07/07/2025 at 10:39 a.m. observation of Resident #74's room revealed the room was excessively dirty with debris and clutter and the room had a strong smell of urine. Further observation revealed a liquid that appeared to be urine all over bathroom floor. Further observation revealed that Resident #74's wheelchair had an excess of dirt and debris with both arm rests damaged. Interview with S2Director of Nursing (DON) on 07/09/2025 at 2:25 p.m. confirmed that staff had problems with keeping Resident #74's room clean and had to move all items out of room recently. S2DON confirmed that the wheelchair was damaged. Resident #76 On 07/07/2025 at 11:00 a.m. an observation of Resident #76's room revealed no linen/covers on her bed. […]