Legendary Health Care Center

In the surveyor’s words

From the most serious findings on record at Legendary Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Mar 4, 2025

  Based on interview and record review, the facility failed to thoroughly assess one resident (Resident #1) and notify the physician after the resident sustained an unwitnessed fall that resulted in increased pain, dizziness, vomiting, and a fractured hip, in a review of 10 sampled residents. After the fall, staff transferred the resident from the floor to the toilet, to a wheelchair, and then to his/her bed. During the transfer, staff said the resident yelled and screamed out in pain. The resident complained of his/her head hurting and feeling dizzy. […]

• Actual harm, isolatedF699May 20, 2025

  Based on observation, interview, and record review, the facility failed to conduct a complete assessment to identify a history of trauma, the presence of symptoms related to the trauma, and triggers that may cause re-traumatization and to develop an individualized care plan with interventions to mitigate and eliminate these triggers for two residents (Residents #30 and #14), in a review of 14 sampled residents. Resident #30 had a diagnosis of post traumatic stress disorder (PTSD, a mental health condition triggered by a terrifying event, either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) related to sexual abuse as a child. […]

• Actual harm, isolatedF692Jun 17, 2021

  Based on observation, interview, and record review, the facility failed to report one resident's (Resident #9's) significant weight loss to the physician, and failed to ensure the registered dietician assessed the resident and made recommendations regarding his/her weight loss. The facility also failed to consistently provide physician ordered interventions to prevent weight loss and failed to offer the resident his/her preferred food items. A sample of 20 residents was selected for review. The facility census was 33. […]

• No harm, potential for more than minimal, widespreadF812May 20, 2025

  Based on observation, interview, and record review, the facility failed to follow proper hand hygiene techniques when preparing and serving food to residents, and failed to ensure food items in the freezers were stored in good condition without freezer burn. The facility census was 31. 1. Review of the facility policy, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, last revised November 2022, showed the following: -Employees must wash their hands: Before coming in contact with any food surfaces, after handling soiled equipment or utensils, and after engaging in other activities that contaminate the hands.; -Gloves are considered single-use items and must be discarded after completing the task for which they are used; -The use of disposable gloves does not… […]

• No harm, potential for more than minimal, widespreadF880May 20, 2025

  Based on observation, interview and record review, the facility failed to follow current infection control standards for three residents (Residents #28, #20 and #19), in a review of 14 sampled residents, when staff failed to follow facility policy related to handwashing and glove usage when providing personal care to the residents. The facility failed to implement the facility policy to address Legionella (a bacterium that can cause a serious type of pneumonia called Legionnaires' Disease (a bacterial disease commonly associated with water-based aerosols) in persons at risk) control that included specific control parameters based on Center for Disease Control and Prevention (CDC) and American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE) standards, and failed to… […]