Legacy Park Health and Rehabilitation

In the surveyor’s words

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

• Actual harm, isolatedF760Feb 27, 2025

  Based on facility policy review, medical record review, hospice medical record review, and interview the facility failed to protect the residents right to be free from a significant medication error for 1 resident (Resident #7) of 3 sampled hospice respite residents. The facility's failure to prevent a significant medication error resulted in actual HARM for Resident #7. The facility's failure to prevent a significant medication error resulted in actual HARM for Resident #7 when the resident's order for Morphine Sulfate was transcribed incorrectly by nursing staff and Resident #7 was administered the medication on a scheduled basis instead of as needed, according to the physician order. […]

• Actual harm, isolatedF600Jun 26, 2023

  Based on facility policy review, medical record review, facility investigation review, and interview the facility failed to protect 3 residents from abuse (Resident #2, Resident #3, and Resident #9) of 9 residents reviewed for abuse when Licensed Practical Nurse (LPN) #1 yelled at and threatened Resident #2, and Certified Nursing Assistant (CNA) #4 refused to provide needed care to Resident #3 and Resident #9. This resulted in Resident #2 and Resident #3 sustaining psychosocial Harm. […]

• Actual harm, isolatedF609Jun 26, 2023

  Based on facility policy review, medical record review, facility investigation review, and interview the facility failed to timely report allegations of abuse to the State Survey Agency for 3 residents (Resident #2, Resident #3, and Resident #9) of 9 residents reviewed for abuse when a Licensed Practical Nurse (LPN) #1 yelled at and threatened Resident #2, and a Certified Nursing Assistant (CNA) #4 refused to provide needed care to Resident #3 and Resident #9. This resulted in Resident #2 and Resident #3 sustaining psychosocial Harm. […]

• Actual harm, isolatedF600Apr 26, 2023

  Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to prevent abuse for 1 resident (Resident #1) of 6 residents reviewed for abuse, when a Certified Nursing Assistant (CNA) had a verbal argument with Resident #1 and then kicked the resident's room door open which resulted in actual psychosocial Harm for Resident #1. The findings include: Review of the facility policy titled, Reporting and Investigation of Resident Abuse, Mistreatment and Neglect, dated 3/2019, showed .It is the policy of this facility that each resident has the right to be free from .verbal .and mental abuse .Definitions .Abuse .the willful or deliberate infliction of .intimidation .with resulting .mental anguish .Mental abuse .includes .humiliation,… […]

• Actual harm, isolatedF607Apr 26, 2023

  Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to revise their abuse policy to meet federally required standards for reporting abuse to the State Survey Agency, resulting in the facility failing to report an allegation of abuse within the federally required time frame for 1 resident (Resident #1) of 6 residents reviewed for abuse, when a Certified Nursing Assistant (CNA) had a verbal argument with Resident #1 and then kicked the resident's room door open which resulted in actual psychosocial Harm for Resident #1 . […]