Legacy Nursing and Rehabilitation of Pollock

Inspectors wroteBased on interview and record review, the facility failed to ensure Residents who are unable to carry out ADLS (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene for 3 (#10, #56, #67) of 4( #10, #56, #67, and #90) Residents reviewed for ADLS. The facility failed to ensure Resident #67 received a bath on his scheduled bath day, and failed to ensure Residents #10 and #56 received appropriate nail care. The total sample size was 37.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services that assured accurate acquiring, receiving, dispensing and/or administration of medications to meet the needs of each resident. The facility had a total census of 86 residents. The facility failed to: 1. Ensure the on-coming nurse (S4 LPN) documented and signed the Narcotic count sheet at the beginning of shift; and 2. Ensure an accurate account for controlled substance medications were completed at the time of administration by S4 LPN on 1 (Cart A) of 2 (Cart A and Cart B) medication carts for Residents #1, #27, #40, #42, #51, #57, #62, #65, #72, #78, and #91.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections by failing to:1. Disinfect reusable medical equipment as required, 2. Maintain soiled linen/soiled items in a sanitary manner;2. Store clean linen in a sanitary manner; and3. Ensure staff were consistent with infection control practices for cleaning/disinfecting the environment.

Inspectors wroteBased on observation, interview and record review the facility failed to promote and facilitate resident self-determination through support of resident choice about aspects of his or her life in the facility that were significant to the resident for 1 (#8) of 37 sampled residents. The facility failed to accommodate Resident #8's choice to have a shower during the mornings instead of during afternoons and evenings.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident's PRN order for psychotropic medication was limited to 14 days for 1 (Resident #90) of 5 residents (#3, #8, #10, #33, and #90) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 1(#14) of 4 (#14, #33, #49, and #75) residents reviewed for respiratory care. The facility failed to ensure respiratory equipment was properly stored.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Resident with dementia received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for 1 (#10) of 5 (#3,#8,#33,#90) Residents reviewed for Dementia. The total sample size was 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with a diagnosis of dementia received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. The facility failed to provide 1:1 observation as ordered for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) residents reviewed for abuse. This deficient practice had the potential to affect all 17 residents residing in the facility's secured unit. Review of Resident #2's medical record revealed an admission date of 07/24/2025 with diagnoses which included Dementia, Anxiety, and Psychosis. Resident #2's admission MDS with an ARD of 08/06/2025 revealed a BIMS score of 3, indicating severe cognitive impairment. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's care plan was revised by failing to update fall interventions after each fall for 1 (#2) of 2 (#1 and #2) residents reviewed for falls.

Inspectors wroteBased on record review and interview, the facility failed to provide services that meet professional standard of practice for 2 (#1 and #2) of 2 sampled residents with falls. The facility failed to ensure neurological checks were completed for 72 hours after an unwitnessed fall or fall with head injury.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent the development of new pressure ulcers for 2 (#1 and #3) of 2 residents investigated for skin issues by failing to: 1. Perform weekly wound assessments for Resident #3's DTI and 2. Perform wound care as ordered for Residents #1 and #3.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's comprehensive person-centered care plan was implemented by failing to administer an antidepressant medication as ordered for 1 (#1) of 3 (#1, #2, and #3) sampled residents reviewed for care planning.

Inspectors wroteBased on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3), sampled residents reviewed for respiratory care. The facility failed to ensure equipment was properly cleaned, labeled and stored.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure services were provided to meet professional standards. The facility failed to: 1. Ensure controlled medications were administered at the time the medication was signed by the nurse as being administered for 9 (#4, #13, #39, #40, #43, #45, #56, #70 and #275) of 13 (#4, #13, #28, #29, #31, #39, #40, #43, #45, #56, #64, #70 and #275) Residents who received controlled medications; and 2. Ensure lab work was drawn in accordance with physician orders for 1 (#7) of 3 (#2, #7 and #21) Residents reviewed for labs.

Inspectors wroteBased on observation, interview, and record review the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the menu in regard to portion size to ensure nutritional adequacy of the meal for 9 residents that received mechanically altered diets prepared by the facility kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that pureed foods were prepared by methods which conserved nutritional value for 9 Residents who were ordered and served pureed diets.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who are unable to carry out ADLS (Activities of Daily Living) received the necessary services to maintain good personal hygiene for 1 (#53 ) of 1 Residents reviewed for ADL's. The facility failed to ensure a Resident (#53) received incontinent care.

Inspectors wroteBased on interview and record review the facility failed to include the Medical Director or designee in the Quality Assessment and Assurance process. Total sample size was 31.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections by failing to ensure staff changed gloves and performed hand hygiene after touching contaminated areas during wound care for 1(#31) of 2 (#31 and #34) residents observed for wound care.

Inspectors wroteBased on record review, and interview the facility failed to ensure residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene for 2 (#1 and #3) of 3 (#1, #2, and #3) sampled residents, and 4 (#R1, #R2, #R3, and #R4) of 6 (#R1, #R2, #R3, #R4, #R5, and #R6 random sampled residents.

Inspectors wroteBased on record review, observation and interview, the facility failed to have sufficient staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident. The facility failed to ensure residents who were unable to carry out ADLs, received the necessary services to maintain good grooming and personal hygiene according to their plan of care, for 2 (#1 and #3) of 3 (#1, #2, and #3) sampled residents, and 4 (#R1, #R2, #R3, and #R4) of 6 (#R1, #R2, #R3, #R4, #R5, and #R6) random sampled residents. The facility also failed to ensure sufficient staff was available to ensure residents who required supervision while smoking, were able to smoke at the appointed times, for 2 (#R5 and #R6) of 2 (#R5 and #R6) random sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of sexual abuse was reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility failed to maintain acceptable holding temperatures for pureed foods during meal service. This deficient practice had the potential to affect the 7 Residents that received pureed meals prepared by the kitchen.

Inspectors wroteBased on observation, interview and record review the Facility failed to ensure a Resident was treated with respect and dignity and cared for in a manner that promotes enhancement of his or her own quality of life. The Facility failed to ensure a Resident's urinary catheter drainage bag was covered to ensure privacy for 1 (Resident #104) of 2 (Resident #104 and Resident #31) Resident's reviewed for dignity in a total sample of 15.

Inspectors wroteBased on interview the facility failed to make efforts to document and resolve grievances for 1 (#42) of 1 sampled residents reviewed for grievances out of a total of 15 sampled residents.