Legacy at Jacksonville

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents environment remained as free of accident hazards as is possible for 1 of 5 residents (Resident #1) reviewed for accident hazards. The facility failed to serve coffee at an appropriate temperature resulting in Resident #1 acquiring burns to his left and right inner thighs from a coffee spill. The noncompliance was identified as PNC. The past noncompliance began on 5/22/26 and ended on 5/23/26. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of burns, infection, and hospitalization.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegations were made, if the events that cause the allegation involve abuse or result in 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 for 1 of 4 (Resident #3) residents reviewed for abuse. LVN B failed to report an allegation of verbal abuse from CNA A involving Resident #3 to the Administrator immediately but no later than 2 hours on 5/1/2026. This failure could place residents at risk of abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs for 1 of 5 residents (Resident # 63), and 5 of 5 medication carts (LVN Cart N#100/200, LVN Cart N#200/300, LVN Cart S#400, RN Cart S#500, and LVN Cart S#600), reviewed for pharmacy services. *LVN D failed to use the proper technique for administration of eye drops for Resident #63 on 4/28/2026. *LVN E signed the controlled substance count sheets for the end of their shift at the beginning of their shift on LVN Cart N#100/200 on 04/29/2026. *LVN D signed the controlled substance count sheets for the end of their shift at the beginning of their shift on LVN Cart N#200/300 on 04/29/2026. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 1 of 4 residents (Resident #92) reviewed for care plans. The facility failed to ensure Resident #92 had a baseline care plan that included interventions to address his admission diagnoses and physician orders within 48 hours of admission. This failure could place newly admitted residents at risk of receiving inadequate care and services.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored securely for one of six halls (Hall 400) reviewed for storage of medications. The facility failed to ensure all drugs and biologicals were securely stored when LVN A took possession of hydrocodone-acetaminophen tablets and kept them for approximately 2 hours while charting. This failure placed residents at risk for drug diversion and consuming non-prescribed medication.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 8 residents (Resident #1) reviewed for care plans. The facility failed to develop a comprehensive care plan that included Resident #1's enhanced barrier precautions related to her feeding tube. This failure could place residents at risk of not having individual needs met and cause residents not to receive needed services.

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 1 of 4 residents (Resident #1) reviewed for infection control. The facility failed to ensure CNA A and LVN B followed enhanced barrier precautions and wore a gown and gloves when providing incontinent care to Resident #1 on 11/10/2025. This failure could place residents at risk for cross contamination and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were informed of how to file a grievance for 8 of 8 confidential interviews reviewed for grievances. Residents were not informed of their right to file a grievance during their stay in the facility. This failure could place residents at risk of a decreased quality of life, decreased awareness of their rights and decreased execution of their rights.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure accurate assessments were completed for 2 of 10 residents (Resident #17and Resident #54) reviewed for accuracy of assessments. The facility failed to ensure Resident #17's quarterly MDS assessment dated [DATE] was not inaccurately coded for restraint use. The facility failed to ensure Residents #54's admission MDS assessment dated [DATE] was accurately coded for Preadmission Screening and Resident Review (PASRR). These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being.

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 1 of 5 residents (Residents #139) reviewed for Enhanced Barrier Precautions. LVN B failed to don (to put on) a gown prior to administering medications through Resident #139's PICC line (A peripherally inserted central catheter, a thin flexible tube inserted into a vein in the upper arm and threaded into a large vein near the heart. This failure could place residents under their care at risk for the transmission of communicable diseases and infections.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 19 residents (Resident #42) reviewed for pharmacy services. LVN A failed to ensure Resident # 42's medications were secure and left physician ordered medications at the bedside. LVN A failed to ensure Resident #42 swallowed her medications. These failures could place residents at risk for not receiving the therapeutic effects of ordered medications and consuming medications that were not ordered for them.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 6 residents (Resident #70) reviewed for medication storage. The facility failed to ensure Resident #70's TUMS, an over-the-counter medication, was properly stored. This failure could place residents at risk for adverse reactions .