Legacy on 10TH Avenue

In the surveyor’s words

From the most serious findings on record at Legacy on 10TH Avenue, in the surveyor’s own words.

• Immediate jeopardy, patternF610Jul 11, 2023

  The facility identified a census of 54 residents. The sample included four residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to protect residents from further abuse during the investigation after independently ambulatory Resident (R) 1 took the keys to R2's electric wheelchair, struck R2 with a cane, and tipped R2 over and out of the wheelchair. On 07/04/23, R1, who had a history of hitting other residents, approached R2 while both residents were outside unsupervised. R1 claimed R2 tried to run him over, and forcibly took the keys to the wheelchair. R1 then picked up R2's cane and began striking R2 in the face and head with the cane. The altercation caused R2's wheelchair to tip over and R2 landed on the ground. […]

• Immediate jeopardy, isolatedF600Jul 11, 2023

  The facility identified a census of 54 residents. The sample included four residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure residents remained free from abuse when independently ambulatory Resident (R) 1 took the keys to R2's electric wheelchair, struck R2 with a cane, and tipped R2 over and out of the wheelchair. On 07/04/23, R1, who had a history of hitting other residents, approached R2 while both residents were outside unsupervised. R1 claimed R2 tried to run him over, and R1 forcibly took the keys to the wheelchair. R1 then picked up R2's cane and began striking R2 in the face and head with the cane. The altercation caused R2's wheelchair to tip over and R2 landed on the ground. […]

• Immediate jeopardy, isolatedF689Apr 18, 2023

  The facility had a census of 54 residents. The sample included 21 residents. Based on observation, interview, and record review the facility failed to ensure an environment free from accident hazards when the facility failed to consistently monitor water temperatures in areas with resident access and failed to ensure the water in Resident (R) 55's bathroom remained at a safe temperature. On 04/18/23 at 10:50 AM, R55 reported an unidentified staff complained to him the water from R55's bathroom sink had scalded the staff. Upon assessment, the temperature of the sink water measured at 143.5 degrees Fahrenheit (F) which was 23 degrees above a safe bathing temperature. […]

• Immediate jeopardy, isolatedF760Apr 28, 2021

  The facility identified a census of 56 residents. Based on record review and interviews the facility failed to prevent a significant medication error when Certified Medication Aid (CMA) R failed to verify the identity of Resident (R) 1 prior to administering medication. On 4/26/21 at 09:22 PM R1 received multiple medications in error, including psychoactive medications (affecting cognition, mood, and/or thoughts). After R1 received the incorrect medications, R1 was unresponsive and in respiratory distress. R1 was sent emergently to an acute care facility, placed on a ventilator for assisted respiration, and admitted to the intensive care unit (ICU). […]

• Immediate jeopardy, isolatedF803Mar 2, 2021

  The facility identified a census of 56 residents. The sample included three residents who received mechanical soft diets (foods that are physically soft, with the goal of reducing or eliminating the need to chew the food). Based on record review and interviews, the facility failed to ensure a mechanical soft menu was followed for Resident (R)1. On [DATE] at approximately 5:50 P.M. R1 received uncut and non-soft Brussel sprouts with the evening meal. R1 experienced choking and required the [MEDICATION NAME] maneuver (a first-aid procedure for dislodging an obstruction from a person's windpipe). […]