Legacies Nursing and Rehabilitation

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure the temperature for the dish machine was at the appropriate temperature of 120 degrees Fahrenheit during the wash cycle according to the manufacturer's guidelines to sanitize dishes appropriately on 03/01/26 through 3/17/26. This failure could place residents who eat from the kitchen at risk of foodborne illnesses.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that each resident had a right to privacy during medical care for 1 of 6 residents (Residents #73) observed for privacy. The facility failed to ensure full visual privacy during incontinent care for Resident #73 on 03/16/2026. This deficient practice placed residents at risk of loss of privacy and dignity.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #1) and 1 of 7 staff (MA C) reviewed for infection control. The facility failed to ensure MA C followed contact precautions for Resident #1 on 3/16/2026. This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 2 of 12 residents reviewed for accident hazards. (Resident #50 and #63). 1. The facility failed to develop and implement a policy and procedure to properly handle the care of mechanical lift slings including interventions to inspect the Hoyer sling for signs of damage before each use and not removing damaged slings from service for Resident #50. 2. NA D failed to properly transfer Resident #63 on 01/14/2025. These deficient practices could place residents at risk of falls and injuries during transfers.

Inspectors wroteBased on interview and record review, the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change of condition for 4 of 6 Residents (Resident #49, Resident #56, Resident #67, and Resident #76) reviewed for PASSAR (Preadmission Screening and Resident Review Services) in that: 1. The facility failed to ensure Resident #49 had a PASSAR level II evaluation completed with a diagnosis of psychotic disorder (abnormal thinking and perceptions). 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 3 residents (Resident #1 and Resident # 24) reviewed for quality of care. The facility failed to ensure Residents #1 and 24's indwelling catheters (drains urine from your bladder into a bag outside your body) had a securement device to anchor their catheters. This failure could place residents at risk for urinary tract infections and catheter related injuries.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 8 staff (CNA G, CNA Q, CNA N) and for 2 of 5 residents reviewed for infection control (Resident #9 and Resident #45). 1. The facility failed to ensure MA P wore gloves when administering eye drops to Resident #45. 2. The facility failed to ensure the Treatment nurse used a clean gauze pad to dry a wound for Resident #9. 3. The facility failed to ensure CNA G, CNA Q, and CNA N washed or sanitized their hands when passing out meal trays to residents on Hall 200 and Hall 300. These failures could place residents at risk of exposure to communicable diseases and infections.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to treat residents with respect and dignity and care for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 1 of 22 residents (Resident #20) and 1 of 10 staff (CNA N) reviewed for resident rights. The facility failed to treat Resident #20 with respect and dignity when she did not receive her lunch meal tray while the other residents seated with her in the dining room were already eating. The facility failed to ensure staff referred to residents in a dignified manner when CNA N referred to residents requiring assistance with meals as feeders where residents could hear her. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increased anxiety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the interdisciplinary team had determined that self-administration of medications by a resident was clinically appropriate for 1 of 4 (Resident #34) residents reviewed for resident rights, in that: The facility failed to assess, obtain physician orders, and interdisciplinary team approval for Resident #34 to self-administer his Ventolin inhaler. This failure placed the resident at risk of not receiving the proper medication or the therapeutic benefits of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 8 residents (Resident #45) reviewed for pharmacy services. The facility failed to ensure MA P held Resident #45's Losartan Potassium 25mg (for high blood pressure) for a blood pressure reading that was lower than ordered parameters. This failure could place residents at risk for inaccurate drug administration resulting in decline in health and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items, per facility policy, for 2 of 7 resident's (Resident #21 and 38) personal refrigerators reviewed for food and nutrition services. The facility failed to ensure the refrigerator for Resident #21 did not contain strawberry and chocolate boostdated 11/5/2023 and 12/5/2023 and a plastic container with something orange that was undated. The facility failed to ensure the refrigerator for Resident #38 did not contain chocolate boost and a bowl of pot pie that was undated. These failures could place residents at risk for food borne illnesses.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside; and toilet and bathing facilities for 1 of 7 residents (Resident #51) reviewed for call lights. The facility failed to ensure Residents #51's emergency call light located in the bathroom would reach the floor. This failure could affect residents who used their call light or desired to use the call light and place them at risk of not being able to notify staff of their needs.