Legend Oaks Healthcare and Rehabilitation -Garland

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600May 14, 2023

  Based on observation, interview and record review, the facility failed to ensure residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, to include corporal punishment, involuntary seclusion for one (Resident #1) of 7 residents reviewed for resident rights. Facility staff failed to provide necessary care and services for Resident #1 to avoid a preventable injury. CNA C was not competent of Resident #1's ADL limitations and supervision requirements. Resident #1 had diagnoses including one sided paralysis, unsteady gait and severe cognitive impairment with a history of documented falls at the facility. Resident #1 required extensive assistance with bathing and was left alone in the shower room to shower. […]

• Immediate jeopardy, isolatedF689May 14, 2023

  Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of seven residents reviewed for accidents and supervision. CNA A failed to provide supervision for Resident #1, who was identified in her MDS Assessment as being totally dependent upon staff with one person assist, while Resident #1 was in the shower. Resident #1 subsequently fell and was found alone on the floor in the shower room. X rays were completed and indicated Resident #1 sustained injury including a fracture of the distal femur(thighbone fracture). She was sent to the hospital for further evaluation and treatment; she did not return to the facility . On 05/12/23 at 12:30 PM an Immediate Jeopardy (IJ) was identified. […]

• Immediate jeopardy, isolatedF578Sep 29, 2021

  Based on interview and record review, the facility failed to honor the resident's right to refuse treatment for 1 (Resident #100) of 18 residents reviewed for advanced directives. The facility failed to ensure Resident #100's updated code status was documented in her physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #100 and witnessed by facility staff. The facility uploaded the form into the electronic charting system but failed to ensure her physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], Resident #100 experienced a change in condition and was sent to the hospital via 911 EMS. The paramedics were provided with Resident #100's incorrect orders which stated she was Full Code status. On the way to the hospital, Resident #100 went into [CONDITION(S)]. […]

• Immediate jeopardy, isolatedF686Sep 29, 2021

  Based on observations, interviews, and record reviews, the facility failed to provide care and treatments, consistent with professional standards, to promote healing of pressure ulcers and to prevent development of new pressure ulcers for one (Resident #87) of one resident reviewed for pressure ulcers. The facility failed to implement wound care as ordered by the physician. Resident #87's stage 2 pressure ulcer to her sacrum/coccyx deteriorated to a stage 3. Resident #87's wounds on left and right arm were not identified, assessed, and treated to promote healing. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:36 PM. The administrator was notified on [DATE] and provided an IJ template. […]

• Actual harm, isolatedF690Sep 29, 2021

  Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services for one (Resident #87) of one residents observed for indwelling urinary catheters. The facility failed to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures could place Resident # 87 at risk for urethral tears, dislodging of the catheter, and urinary tract infections. Findings included: Review of Resident #87's quarterly MDS Resident Assessment , dated 08/21/21, revealed she was a [AGE] year old female who admitted to the facility on [DATE]. Her active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]