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, patternF656Apr 23, 2024

  Based on observation , interview and record review the facility failed to develop and implement a comprehensive care plan to meet the highest practicable physical, mental, and psychosocial wellbeing for 1 (Resident #1) of 5 residents reviewed for care plans. 1.The facility failed to develop and implement a Care Plan for Resident #1's fall out of bed on 12/13/2023 and as a result, Resident #1 suffered a second fall out of bed on 4/1/2024. Resident #1 was hospitalized with a fractured hip from 12/13/2023 to 12/28/2023. Resident #1 was hospitalized from 4/1/2024 to 4/11/2024 due to second fall on 4/1/2024. An IJ was identified on 4/18/2024. The IJ template was provided to the facility on [DATE] at 5:23pm. […]

• Immediate jeopardy, patternF689Apr 23, 2024

  Based on observation, interview and record review the facility failed to provide supervision to prevent accidents for 1 (Resident #1) of 5 residents reviewed for accidents. The facility did not provide adequate supervision for Resident #1 while giving a bed bath on two separate occasions causing her to fall off the bed resulting in prolonged hospital stays. Resident #1 was hospitalized with a fractured hip from 12/13/2023 to 12/28/2023 after she rolled off the side of the bed during a bed bath. Resident #1 was hospitalized from 4/1/2024 to 4/11/2024 after she rolled off the side of the bed during a bed bath. An IJ was identified on 4/18/2024. The IJ template was provided to the facility on [DATE] at 5:23pm. […]

• Actual harm, isolatedF689Aug 13, 2026

  Based on interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (Resident #54) reviewed for accidents. CNA A was turning Resident #54 and he fell while performing ADL care to Resident #54 on 7/23/26 resulting in the resident rolling over, falling and sustaining an orbital fracture (one or more of the bones surrounding the eye were broken) and stitches on his forehead. The non-compliance was identified as Past non-compliance. the non-compliance began on 07/23/26 and ended on 07/24/26. The facility corrected the non-compliance before the survey began. […]

• Actual harm, isolatedF684Sep 29, 2021

  Based on interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 5 residents (Residents #1) reviewed for quality of care. The facility failed to assess, develop and implement interventions to reduce the risk of falls or injury for Resident #1 after she sustained a fall with major injury ( fracture of the upper arm ) during a one person assist incontinent care. […]

• No harm, potential for more than minimal, widespreadF812May 10, 2024

  Based on observation, interview and record review the facility failed to serve food in accordance with professional standards for food safety in one of one kitchens, in that: - The facility failed to test and maintain proper concentration level of sanitizer solution during the dishwasher's wash cycle This failure could affect all residents by placing them at risk for food-borne illness. Findings included: Observation of the kitchen on 05/07/2024 at 9:05am revealed, after breakfast was already served to residents on plates and utensils, the facility's only low-temp dishwasher, in use at the time, failed to dispense the correct amount of sanitizer solution during the wash cycle. […]