Legend Oaks Healthcare and Rehabilitation - North

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Sep 17, 2025

  Based on observations, interviews and record reviews the facility failed to ensure the facility did not use physical abuse for 1 of 2 Residents. The facility failed to ensure Resident #1 was free from abuse when CNA A and CNA B were changing the briefs of Resident # 1 on 08/17/2025. This failure could place residents at risk for serious psychosocial harm from abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life.Findings included: Record review of Resident #1's admission Record, dated 09/03/25, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. […]

• Immediate jeopardy, isolatedF607Sep 17, 2025

  Based on observation, interview, and record review, the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for one of one resident (Resident #1) reviewed for abuse, neglect, and exploitation. The facility failed to implement their policies and procedures to ensure Resident #1 was free from abuse when the facility failed to have effective interventions and services in place to address the resident's care, which resulted in Resident #1 sustaining Comminuted (bone that is broken in at least two places),(mildly displaced fracture of the base of the right first digital proximal phalanz (most basal bones of each digit.)with extension to the first digit joint… […]

• Immediate jeopardy, isolatedF600Oct 16, 2022

  Based on observations, interviews, and record reviews the facility failed to prevent the use of verbal, mental, physical abuse, and/or corporal punishment for 2 of 3 residents (#24 and #75) reviewed for abuse. 1. Resident #24 experienced a fractured wrist when CNA A attended her bedside. The facility did not assess all residents for safety. The facility did not in-service all staff for abuse, neglect, exploitation prevention. 2. Resident #75 was a victim of verbal/mental abuse that resulted in Resident #75 being sent to the hospital via ambulance and received medications. An IJ was identified on 10/14/2022. The IJ began on 10/3/2022 and removed on 10/4/2022. The facility took action to remove the IJ before the survey began. […]

• No harm, potential for more than minimal, patternF550Apr 23, 2026

  Based on observation, interview and record review, the facility failed to care for residents in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for three (Resident #3, Resident #31, and Resident #106) out of 10 residents reviewed for resident rights. The facility failed to knock on Resident #3's, Resident #31's and Resident # 106's doors prior to entry when going into the residents' rooms. The deficient practice could place residents at risk of feeling like their privacy is being invaded or the facility is not their home. Findings included: Review of Resident #3's Face Sheet dated 04/23/26 revealed he was a [AGE] year-old male who was readmitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF803Apr 23, 2026

  Based on observation, interview, and record review, the facility failed to follow menus for 3 (Resident #2, Resident #23, and Resident #88) of 3 residents reviewed for a pureed diet. The facility failed to use a large enough scoop when serving residents on a pureed diet on 4/21/26, 4/22/26, and 4/23/26. This failure placed residents at risk for decreased intake and weight loss.Findings included: A record review of Resident #2's face sheet dated 4/23/2026 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of cerebral infarction (stroke), atrial fibrillation (irregular heartbeat), dysphagia (difficulty swallowing), pneumonitis (inflammation of the lung) due to inhalation of food and vomit, muscle wasting and atrophy (muscle loss), cognitive communication deficit (difficulty… […]