Legacy Nursing and Rehabilitation Winnsboro

Inspectors wroteResident #74 On 07/07/2025 at 10:39 a.m. observation of Resident #74's room revealed the room was excessively dirty with debris and clutter and the room had a strong smell of urine. Further observation revealed a liquid that appeared to be urine all over bathroom floor. Further observation revealed that Resident #74's wheelchair had an excess of dirt and debris with both arm rests damaged. Interview with S2Director of Nursing (DON) on 07/09/2025 at 2:25 p.m. confirmed that staff had problems with keeping Resident #74's room clean and had to move all items out of room recently. S2DON confirmed that the wheelchair was damaged. Resident #76 On 07/07/2025 at 11:00 a.m. an observation of Resident #76's room revealed no linen/covers on her bed. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure Minimum Data Set (MDS) Assessments were completed and transmitted timely for 4 (#34, #35, #55, and #59) of 4 sampled residents reviewed for resident assessment.

Inspectors wroteBased on observations, policy review and interviews, the facility failed to store food and discard expired items in accordance with professional standards for food service safety. This deficient practice had the potential to effect the 63 residents that received meals prepared in the facility's kitchen.

Inspectors wroteBased on record reviews, observations, and interviews the facility failed to maintain electrical equipment in safe operating condition for 1 (#70) of 7 (#1, #5, #25, #70, #71, #74, #76) residents reviewed for environment. The facility failed to ensure that Resident #70's bed control was properly maintained and in safe working order.

Inspectors wroteBased on record review, observation, and interview the facility failed to treat the resident with respect and dignity and care in a manner and in an environment that promotes or enhances his or her quality of life for 1 (#76) of 1 residents reviewed for dignity. The facility failed to ensure that Resident #76's privacy was maintained.

Inspectors wroteBased on record review and interview, the facility failed to complete a discharge summary for 1 (#89) of 1 closed records reviewed.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADL) received the necessary services to maintain good personal hygiene for 2 (#11, #22) of 6 (#11, #14, #22, #56, #70, #74) residents reviewed for ADL care.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 (#1) of 1 residents reviewed for position/mobility. The facility failed to ensure hand rolls and an elbow splint were provided for Resident #1's hand and arm contractures.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to ensure the resident's environment remained free of accident hazards by failing to ensure bed rails were properly secured for 1 (#5) of 2 (#5, #11) residents reviewed for accident hazards.

Inspectors wroteResident #1 Review of the record for Resident #1 revealed an admit date of 05/01/2005 with diagnoses of hemiplegia, unspecified affecting unspecified side, and traumatic hemorrhage of cerebrum. Review of the current physician orders for Resident #1 revealed an order for oxygen therapy as follows: oxygen saturation level each shift, apply oxygen if saturation less than 92% at 2 liters per nasal cannula. Review of the care plan revealed a plan for at risk for respiratory infection related to Covid with interventions to administer oxygen as ordered. Observation of Resident #1 on 07/07/2025 at 8:23 a.m. revealed the oxygen concentrator flow set to three liters. Further observation revealed that the oxygen nasal cannula was lying on the floor. Further observation revealed that the concentrator was filthy with white debris splattered on it. Observation of Resident #1 on 07/07/2025 at 1:30 p.m. [...]

Inspectors wroteBased on observations of the medication administration, record review, and interview, the facility failed to ensure that it was free from a medication error rate of 5% or greater. The facility had a 5.41 % medication error rate with 2 medication errors out of 37 opportunities.

Inspectors wroteBased on record review and interview, the facility failed to ensure that nursing staff are able to demonstrate competency in skills necessary to care for resident needs for 2 (#1,#2) of 3 (#1,#2,#3) residents records reviewed. The facility did not have documentation of wound care being provided daily as ordered.

Inspectors wroteBased on interviews, observations, and record reviews, the facility failed to ensure a resident admitted with a urinary catheter received necessary treatment and services, consistent with professional standards to promote healing and prevent infections for 1 (#9) of 3 (#9, #40, and #231) sampled residents reviewed for urinary catheters. This failed practice resulted in actual harm for resident #9 on 04/16/2024 due to the facility failing to: 1. Ensure resident #9 was free of urinary tract infections as evidenced by resident #9 having a urinary tract infection on 04/16/2024 and again on 05/13/2024, and was treated with antibiotic therapy on both occasions for 5 days, beginning respectively on 04/17/2024 and 05/13/2024. 2. Assess the medical justification for the indication for use of a urinary catheter for resident #9 upon admission on [DATE]. 3. [...]

Inspectors wroteBased on record reviews, observations and interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming and personal hygiene for 3 (#51, #55, & #57) of 5 (#4, #38, #51, #55, & #57) sampled residents reviewed for activities of daily living (ADLs).

Inspectors wroteBased on record reviews and interviews, the facility failed to assure that nursing staff possessed the competency to provide nursing related services as evidenced by S2Director of Nursing (DON), S12Licensed Practical Nurse (LPN)/Minimum Data Set (MDS) Coordinator, and S13Nurse Practitioner (NP) failing to ensure a resident admitted with a urinary catheter had a medical justification for the indication/use of a urinary catheter for 1 (#9) of 3 (#9, #40 and #231) sampled residents reviewed for urinary catheters.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure that each resident received adequate supervision to prevent accidents for 1 (#51) of 3 (#51, #61 & #62) sampled residents reviewed for falls.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure that a resident maintains acceptable parameters of nutritional status for 1 (#51) of 1 (#51) resident reviewed for nutrition. The facility failed to provide the required assistance with meals to prevent significant weight loss.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 (#10) of 1 sampled residents reviewed for respiratory care. The facility failed to ensure the oxygen tubing and cannula were stored properly when not in use for resident #10.

Inspectors wroteBased on record reviews and interview, the pharmacist failed to report any irregularities to the attending physician and the facility's medical director and director of nursing for 1 (#30) of 1 sampled resident who received an anticoagulant medication. The pharmacist failed to identify that the facility had not monitored resident #30 for bleeding while the resident was receiving an anticoagulant medication.

Inspectors wroteBased on record reviews and interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 (#30) of 1 sampled resident who received an anticoagulant medication. The facility failed to monitor resident #30 for bleeding when administered an anticoagulant medication.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a resident received the necessary care and services in accordance with the residents comprehensive and professional standards of practice by failing to provide wound care as ordered for 2 (#1,#4) of 4 (#1,#2,#3,#4) residents reviewed for wound care.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that nursing staff possessed the competency to provide nursing related services as evidenced by S5Nurse Practitioner (NP) failing to 1.) provide to the facility progress notes in a timely manner for 2 (#1 and #4) of 4 (#1, #2, #3, and #4) residents, and 2.) ensure results of laboratory culture analysis were provided to the facility in a timely manner for 2 (#1 and #4) of 4 (#1, #2, #3, and #4) residents reviewed for wound care and lab services.

Inspectors wroteBased on interviews, observations, and record reviews, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards to promote healing and prevent infection for 1 (#1) of 3 (#1, #2, and #3) sampled residents reviewed for pressure ulcers. Resident #1 experienced a delay in the initiation of antibiotic therapy.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to protect the residents' right to be free from physical and verbal abuse and psychosocial harm by staff for 1 (#7) of 4 (#1, #4, #5, and #7) sampled residents. The actual harm resulted for resident #7, who was cognitively impaired, on 02/13/2024 at approximately 1:12 p.m. when S3Certified Nursing Assistant (CNA) was witnessed being physically and verbally abusive to resident #7. S3CNA was witnessed by two Licensed Practical Nurses (LPNs) aggressively pull resident #7 up from her geri-chair and then popped her on the behind. S3CNA also was witnessed telling resident #7 to stop f______ pulling that sh__ down, I'm tired of the f______ sh__. [...]

Inspectors wroteBased on record review and interviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately for 1 (#1) of 4 (#1, #4, #5, and #7) sampled residents. The facility failed to ensure staff followed the facility's Abuse policy regarding reporting the suspected abuse immediately to the Administrator or Director of Nursing (DON).

Inspectors wroteBased on record review and interviews the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs by not performing a body audit after a resident had a fall from a wheelchair to the floor for 1 (#1) of 4 (#1, #4, #5 and #7) sampled residents.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 (#40) of 1 (#40) residents who had medications stored in their rooms.