Legends Care Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Legends Care Rehabilitation and Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Mar 20, 2025

  Based on observation, medical record review, review of hospital records, review of facility Self-Reported Incidents (SRI), review of facility abuse investigations, review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property, review of the facility policy titled Resident Rights, and interviews, the facility failed to ensure Resident #23 and Resident #38 were free from incidents of resident to resident physical and verbal abuse. This resulted in Immediate Jeopardy and actual harm beginning on 02/04/25 at approximately 8:30 P.M. when Resident #38 was abused by Resident #15, a resident who was identified to not like other residents in his space or touching his things. […]

• Immediate jeopardy, isolatedF678Mar 20, 2025

  Based on closed record review, facility policy review and interview, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) or call 911 for Emergency Medical Services (EMS) for Resident #60, who was found unresponsive, without a pulse/heartbeat and was identified to have advance directives reflecting the resident was a Full Code status. This resulted in Immediate Jeopardy and serious life-threatening harm/death on [DATE] when staff failed to initiate CPR or call 911 for medical services assistance when the resident was found unresponsive. Resident #60 subsequently passed away. This affected one resident (#60) of three residents reviewed for death in the facility. […]

• Actual harm, isolatedF689May 14, 2024

  Based on record review and interview the facility failed to provide adequate intervention and update Resident #61's care plan related to the resident's known use of a bed remote control to prevent a fall with injury. This affected one resident (#61) of four reviewed for person centered care planning. The facility census was 58. Actual harm occurred on 04/20/24 at approximately 2:30 A.M. when Resident #61, who had impaired cognition and a history of using the bed remote control to place her bed in the highest position without having the cognitive ability to lower the bed, was found on the floor yelling out in pain with both of her legs bent behind her with bones protruding from the skin. Resident #61's bed was noted in the high position when she was found on the floor. […]

• Actual harm, isolatedF684Oct 21, 2022

  Based on observation, record review, facility policy and procedure review and interview the facility failed to prevent the worsening of a surgical wound for Resident #4 and failed to ensure wound treatment was provided as ordered for Resident #4 and Resident #2. This affected two residents (#4 and #2) of four residents reviewed for non-pressure skin wounds. Actual Harm occurred on 07/21/22 when Resident #4, who was cognitively impaired, and at risk for skin breakdown was found to have a worsening ulceration of a surgical wound, located on the lower, left, lateral leg. The facility failed to provide wound care as ordered and the wound worsened and subsequently required treatment and debridement at a wound clinic. […]

• No harm, potential for more than minimal, widespreadF812Jun 18, 2024

  Based on observations, review of pest control invoices, review of pest control logs, interview with staff, and review of the facility policy the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect 51 residents who received meals from the kitchen. Two residents (#31 and #33) were identified by the facility as receiving nothing by mouth. The facility census was 53. Findings include: 1. Observation of the kitchen on 06/13/24 at 9:00 A.M. with [NAME] #122 revealed the stainless-steel table by the dishwasher, which had the chemical on it, was dirty with food debris and dirt, the stainless-steel table, by the steam table revealed the bottom shelf was dirty with food debris and dirt buildup, the stainless-steel table the coffee maker was on, had dirt on… […]