Legend Oaks Healthcare and Rehabilitation - West S

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 12, 2024

  Based on observation, interviews, and record reviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 of 5 residents (Resident #1 and Resident #2) reviewed for adequate supervision in that: The facility did not put in place adequate supervision for Resident #1 who had a history of suicidal ideations and a Major Depression diagnosis. On 03/21/24 at 10:30 AM, he was found slumped over on a W/C in his room after he tried to commit suicide by ingesting mouthwash. […]

• No harm, potential for more than minimal, widespreadF576Oct 31, 2024

  Based on interview and record review, the facility failed to promote the residents' right to receive mail, for all facility residents, in that: Facility staff did not distribute mail received on Saturdays to the residents. This deficient practice could result in residents not receiving mail in a timely manner and a diminished quality of life. The findings were: During a confidential group meeting on 10/30/24 at 2:30 p.m., members of the resident group stated that they do not receive mail on Saturdays and stated they feel this practice was disrespectful. During an interview with the ADON on 10/31/2024 at 9:30 a.m., the ADON stated mail was not delivered to resident's on Saturdays, unless they came up to the receptionist and asked for their mail. […]

• No harm, potential for more than minimal, patternF550Jun 12, 2026

  Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (Resident #1) out of 6 residents reviewed for dignity. The facility failed to comply with Resident #1's request not to have CNA G assigned to her care and to not enter her room. This failure could place residents at risk of diminished dignity and affect their quality of life.The findings included: Record review of Resident #1's admission Record, dated 06/11/2026, revealed an [AGE] year-old female admitted [DATE] and re-admitted [DATE]. Resident #1 was listed as her own responsible party. […]

• No harm, potential for more than minimal, patternF609Jun 12, 2026

  Based on observation, interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources are reported immediately but not later than 2 hours (for an injury of unknown origin involving serious bodily injury) or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 1 (Resident #1) out of 6 residents reviewed for abuse. […]

• No harm, potential for more than minimal, patternF641Jan 29, 2026

  Based on interview and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 3 of 6 residents (Resident #17, Resident #78, and Resident #108) who were reviewed for resident assessments. 1.The facility failed to correctly document Resident #17's use of insulin injections on the quarterly MDS assessment. 2.The facility failed to correctly document Resident #78's use of insulin injections on the quarterly MDS assessment. 3.The facility failed to correctly document Resident #108's use of insulin injections on the quarterly MDS assessment. These failures could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.The findings included: 1. […]