Legend Oaks Healthcare and Rehabilitation Center -

In the surveyor’s words

From the most serious findings on record at Legend Oaks Healthcare and Rehabilitation Center -, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Oct 6, 2021

  Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 13 residents (Resident #1) reviewed for quality of care in that: RN E and LVN C failed to notify Resident #1's provider, NP A, of Resident #1's abnormal radiology results after resident had experienced nausea and vomiting and been administered anti-nausea medication for 3 days. As a result, Resident #1 was eventually transported to an acute care hospital and expired. This failure resulted in the identification of an Immediate Jeopardy (IJ) on [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Jul 28, 2023

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. There was a zipper-sealed bag in the reach in cooler filled with cut lettuce leaves that were brown. 2. There was a clear plastic storage container of food thickener in the dry storage room that was not properly sealed. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 07/25/2023 at 2:55 p.m. in the reach in cooler revealed a zipper-sealed bag that was filled with cut Romaine lettuce leaves. […]

• No harm, potential for more than minimal, patternF690Dec 4, 2025

  Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 (Resident #13 and #126) of 3 residents reviewed for incontinence care. 1. CNA-B did not clean Resident #13's pubic area and did not open the labia and thoroughly clean the vaginal area for Resident #13 during incontinence care. 2. CNA-C did not clean Resident #126's pubic area during incontinence care. This failure could place residents who required incontinence care at risk for cross contamination and the development of urinary tract infections. The findings included: 1. […]

• No harm, potential for more than minimal, patternF655Sep 27, 2024

  Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 3 residents (Resident #226, Resident #221 and Resident #320) reviewed for comprehensive care plans in that: 1. The facility failed to ensure Resident #226's use of bed rails was care planned. 2. The facility failed to ensure Resident #221's use of bed rails was care planned. 3. […]

• No harm, potential for more than minimal, patternF700Sep 27, 2024

  Based on observation, interview and record review, the facility failed to assess the resident for risk of entrapment from bed rails prior to installation and review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 3 residents of 9 residents (Resident #226, Resident #221, and Resident #320) reviewed for use of side or bed rails in that: 1. The facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail for Resident #226 and failed to assess Resident #226 for risk of entrapment from bed rails before they were installed. 2. […]