Legacy on 10th Avenue

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure there was sufficient nursing staff on the weekends to provide care to each resident's basic and individual needs.

Inspectors wroteThe facility identified a census of 54 residents. The facility had one kitchen and a dining area. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to dirty dishes, food storage, and nonworking equipment.

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure Licensed Nurse (LN) on staff had and retained a valid active nursing license.

Inspectors wroteThe facility had a census of 54 residents. Based on observation, interview, and record review, the facility failed to follow the pest control recommendations.

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure nurse aides received the required 12 hours of in-service training.

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents. Based on observation and interviews, the facility failed to provide a clean, home-like environment for the residents who resided in the facility.

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents, with four medication carts and two medication rooms. Based on observation, record review, and interviews, the facility failed to ensure an accurate reconciliation of controlled drugs at the end of daily work shifts.

Inspectors wroteThe facility identified a census of 54 residents. The facility had four medication carts and two medication rooms. Based on observation, record review and interview, the facility failed to ensure that medication carts were not left unlocked and unattended by staff and failed to ensure that medications and stock medication/supplements in a medication room were discarded when expired.

Inspectors wroteThe facility identified a census of 54 residents. The facility identified nine residents on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to ensure Resident (R)49's, R26's R6, and R30 nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) masks were stored in a sanitary manner when not in use. The facility failed to ensure R44's nasal canula was stored in a sanitary manner when not in use. The facility further failed to ensure clean laundry was stored in a sanitary manner. The further failed to ensure the ice scoop was stored in a sanitary manner. [...]

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents, with one resident reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 52 and their representative were provided with a written notification of transfer, which included where, why, and a statement of the right to appeal and the state ombudsman information, upon their transfer to the hospital as soon as practicable.

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents with two residents reviewed for falls. Based on interviews, observation, and record review the facility failed to ensure fall interventions were implemented as care planned for Resident (R) 6 when staff failed to ensure his call light was within reach.

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents with five reviewed for immunization status. Based on record reviews and interviews, the facility failed to offer or obtain informed declinations, consent, or a physician-documented contraindication for the influenza (highly contagious viral infection that attacks the lungs, nose, and throat and can be deadly in high-risk groups) vaccination for Resident (R) 26 and R8. The facility also failed to offer or obtain informed declinations, consent, or a physician-documented contraindication for the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial infections), pneumococcal (type of bacterial infection) for R8.

Inspectors wroteThe facility identified a census of 54. The sample included 14 residents with four residents reviewed for beneficiary notification. Based on record review and interviews, the facility failed to provide the correct Form CMS 10055- Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) to Resident (R) 56 and R57 and/or their representative.

Inspectors wroteThe facility identified a census of 54 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure that daily posted nurse staffing information was retained for the required amount of time. The facility also failed to ensure that daily nurse staffing information was posted for each day.

Inspectors wroteThe facility identified a census of 53 residents. The sample included five residents reviewed for accidents and falls. Based on observation, record review, and interview, the facility failed to ensure that staff placed and secured Resident (R) 1's wheelchair and the safety belt properly used in the facility's transportation van prior to engaging the vehicle to drive. This resulted in R1's wheelchair overturning, and R1 fell from his wheelchair. This placed R1 at risk of injury and likely harm.

Inspectors wroteThe facility identified a census of 55 residents. The sample included 15 residents. Based on interviews and record reviews, the facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during both day-to-day operations and emergencies. This placed all residents in the facility at risk for unidentified care needs and inadequate care. Findings Included: - On 10/08/24 at 08:00 AM an inspection of the Facility Assessment dated 08/06/24 provided by the facility revealed the following: The assessment lacked information stating the specific staffing needed for each unit including nights and weekends and lacked the number of Registered Nurses (RN), Licensed Nurses (LPN/LVN), Certified Medication Aides (CMA), and Certified Nurse Aides (CNA) needed for each unit. [...]

Inspectors wroteThe facility identified a census of 55 residents. The facility identified 29 residents with facility-managed trust accounts. Based on observation, record review, and interviews, the facility failed to ensure residents had same-day access to their funds for amounts less than $100.00. This deficient practice placed 29 residents at risk for decreased psychosocial well-being and impaired rights. Findings Included: - A review of the facility's Resident Funds accounts revealed 29 residents had active trust accounts with the facility. On 10/07/24 at 07:05 AM an inspection of the central hallway door revealed a sign that read Bank open 3pm to 5pm on Monday through Fridays. On 10/07/24 at 02:20 PM Resident (R)31 sat outside the business office. R31 reported he was waiting for the bank to open so he could get some money out of his account. [...]

Inspectors wroteThe facility identified a census of 55 residents. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to promote a sanitary, homelike environment. This deficient practice had the potential for decreased psychosocial well-being and impaired safety and comfort for the affected residents. Findings Included: - On 10/07/24 at 07:00 AM upon entrance to the facility a strong urine odor was evident in the west and central hallways. On 10/07/24 at 07:03 AM an inspection of the dining hall area revealed multiple food trays with the previous evening's partially eaten taco and sloppy joe meals on a kitchen transport cart. Several flies were observed landing on the food. An inspection of the dining hall revealed flies in the area of the exposed food and trays. [...]

Inspectors wroteThe facility identified a census of 55 residents. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to implement a system to allow residents and their representatives to file grievances anonymously. This deficient practice placed the residents at risk for decreased psychosocial well-being and unresolved grievances and concerns. Findings Included- - On 10/07/24 at 08:10 AM an inspection of the facility revealed no designated grievance drop boxes or system available in the areas accessible to the residents and visitors of the facility. On 10/08/24 at 01:21 PM, the Resident Council members reported they were not aware that the facility provided a way to complete anonymous grievances. The council reported they must take the grievance to a staff member. [...]

Inspectors wroteThe facility identified a census of 55 residents. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to provide consistent activities for the residents. This deficient practice placed the affected residents at risk for decreased psychosocial well-being, isolation, and boredom. Findings Included: - An inspection of the September 2024 activity calendar indicated the residents were to have four scheduled staff-led activities throughout the day for each day. The calendar indicated staff-led activities would be held on or around 08:00 AM-0900 AM, 10:00 AM-11:00 AM, 01:00-02:00 PM, and 06:00-0700 PM with varied events like coffee chat, crafts, social hours, Bingo, and trivia. Observation on 10/08/24 from 07:00 AM through 05:00 PM revealed no staff-led morning or afternoon activities were observed for the residents. [...]

Inspectors wroteThe facility identified a census of 55 residents. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to provide a certified activity professional to direct the activities program in the facility. This deficient practice placed the affected residents at risk for impaired quality of life. (refer to F679) Findings Included: - An inspection of the September 2024 activity calendar indicated the residents were to have four scheduled staff-led activities throughout the day for each day. The calendar indicated staff-led activities would be held on or around 08:00 AM-0900 AM, 10:00 AM-11:00 AM, 01:00-02:00 PM, and 06:00-0700 PM with varied events like coffee chat, crafts, social hours, Bingo, and trivia. The facility was unable to provide evidence for an activity coordinator as requested on 10/07/24. [...]

Inspectors wroteThe facility identified a census of 55 residents. The sample included 15 residents with four reviewed for accidents. Based on observation, record review, and interview the facility failed to secure potentially hazardous equipment, oxygen tanks, and chemicals in a safe, locked area, and out of reach of eleven cognitively impaired independently mobile residents. This placed the affected residents at risk for preventable accidents and injuries. Findings Included: - On 10/07/24 at 07:05 AM a walkthrough of the facility was completed and revealed the following: An unsecured oxygen storage room contained 40 pressurized supplemental oxygen cylinders in the storage rack. The central and west hallways revealed unsecured furnace closets. The west hallway also had multiple bottles of bleach wipes stored in a storage room (room [ROOM NUMBER]) with the door propped open. [...]

Inspectors wroteThe facility identified a census of 55 residents. The facility failed to ensure staff performed adequate hand hygiene, ensure respiratory equipment was stored in a sanitary manner, and further failed to ensure linens were stored in a sanitary manner. These deficient practices placed the residents at risk for infectious diseases.

Inspectors wroteThe facility identified a census of 55 residents. The sample included 15 residents. Based on record reviews, interviews, and observations, the facility failed to provide effective pest control to ensure the facility was free from pests. This placed the residents at increased risk for impaired comfort and disease. Findings Included: - A review of the facility's pest control Service Inspection Report revealed an inspection was completed on 10/07/24 at 09:00 AM and indicated Dietary Staff BB reported no pest concerns. The report noted fly bait traps were placed around the dining and vending machine areas. Observation on 10/07/24 at 07:00 AM of the dining hall area revealed multiple food trays with the previous evening's exposed and partially eaten taco and sloppy joe meals on a kitchen transport cart. There were several flies observed landing on the food. [...]

Inspectors wroteThe facility had a census of 55 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to include Resident (R) 50's representative in the development and planning of the resident's care plan, which placed R50 at risk of impaired care and decreased autonomy. Findings Included: [...]

Inspectors wroteThe facility identified a census of 55 residents. The sample included 15 residents. One resident was sampled for reasonable accommodations of resident needs. Based on observation, record review, and interview, the facility failed to ensure Resident (R)50's call light was within his reach. This deficient practice left R50 vulnerable to unmet care needs due to the inability to call for staff assistance. Findings Included: [...]

Inspectors wroteThe facility identified a census of 55 residents. The sample included 15 residents with one reviewed for notification of changes. Based on observation, record review, and interviews, the facility failed to notify Resident (R)50's representative of changes related to falls. This deficient practice placed R50 at risk for uninformed treatment or care decisions.

Inspectors wroteThe facility identified a census of 55 residents. The sample included 15 residents with five reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure the Consulting Pharmacist (CP) identified and reported the inappropriate indication or lack of diagnosis for Resident (R)4's Risperdal (antipsychotic medication used to treat major mental conditions that cause a break from reality). This deficient practice placed R4 at risk for unnecessary medications and side effects. Findings Included: [...]

Inspectors wroteThe facility identified a census of 55 residents. The sample included 15 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to obtain the physician-ordered test to monitor for side effects related to the use of psychotropic (alters mood or thought) medication for Resident (R) 21. The facility also failed to ensure R4 had a Center for Medicare and Medicaid Services (CMS) approved indication or appropriate diagnosis for the use of an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality). These deficient practices placed the residents at risk for adverse medication effects and unnecessary medications. Findings Included: [...]

Inspectors wroteThe facility identified a census of 55 residents. The sample included 15 residents with three residents reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a collaborated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R)51. This deficient practice created a risk for missed or delayed services and impaired care for R51. Findings Included: [...]

Inspectors wroteThe facility identified a census of 55 residents. The sample included 15 residents. Based on interviews, the facility failed to provide mail delivery on Saturdays.

Inspectors wroteThe facility reported a census of 55 residents. The sample included 15 residents. Based on observation, record review and interviews, the facility failed to maintain 18 months of daily posted nurse hours as required. Findings Included: - On 10/07/24 at 07:02 AM an inspection of all unit's nursing stations revealed the required daily posted staffing sheets posted on each unit. A review of the facility's Daily Posted Staffing from 05/01/23 to 10/07/24 was completed. The review revealed missing daily posted staffing sheets from 05/01/23 through 11/30/23. On 09/08/24 at 09:01 AM Administrative Nurse D stated she was only able to find the posted staffing sheet from December 2023 to the present due to the previous management team not filing them. [...]

Inspectors wroteThe facility identified a census of 53 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to provide a written notification of transfer to Resident (R) 1 or his representative. This deficient practice had the risk for miscommunication between the facility and resident/representative and possible missed opportunities for healthcare services.

Inspectors wroteThe facility identified a census of 53 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to provide a bed hold policy notice to Resident (R) 1 or his representative when he was transferred to the hospital. This deficient practice had the risk of impaired ability to return to the facility and to the previous room for R1.

Inspectors wroteThe facility identified a census of 54 residents. Based on observation, record review and interview the facility failed to ensure an accurate and consistent reconciliation of all controlled substances on the medication carts. This placed the residents at risk for misappropriation and ineffective medication regimens.

Inspectors wroteThe facility identified a census of 52 residents. The sample included three residents reviewed for urinary catheter (flexible tubing inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care. Based on record review, interview, and observation, the facility failed to ensure Resident (R)1, who had an indwelling catheter, had a physician order for the catheter which included the diagnosis or indication for the indwelling catheter. This placed the resident at risk for catheter related complications.

Inspectors wroteThe facility identified a census of 52 residents. The sample included three residents reviewed for urinary catheter (flexible tubing inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care. Based on record review, interview, and observation, the facility failed to ensure Resident (R)2 received appropriate treatment and services related to her nephrostomy (an artificial opening created between the kidney and the skin which allows for the urinary diversion) catheter. This placed R2 at risk for complications related to her nephrostomy catheter.

Inspectors wroteThe facility identified a census of 55 residents. The sample included three residents with one reviewed for transfer and discharge. Based on record review and interview, the facility failed to provide written notice of discharge for Resident (R)1's immediate involuntary discharge. This placed the resident at risk for impaired rights.

Inspectors wroteThe facility had a census of 54 residents. The sample included 21 residents. Based on observation, interview, and record review the facility failed to ensure an environment free from accident hazards when the facility failed to consistently monitor water temperatures in areas with resident access and failed to ensure the water in Resident (R) 55's bathroom remained at a safe temperature. On 04/18/23 at 10:50 AM, R55 reported an unidentified staff complained to him the water from R55's bathroom sink had scalded the staff. Upon assessment, the temperature of the sink water measured at 143.5 degrees Fahrenheit (F) which was 23 degrees above a safe bathing temperature. At 11:10 AM, Administrative Staff A rechecked the water temperature and verified it was 141 degrees F at that time, which was too hot, per Administrative Staff C. This failure placed R55 in immediate jeopardy. [...]

Inspectors wroteThe facility had a census of 54 residents. The sample included 21 residents. Based on observation, record review, and interview the facility failed to provide the services of a full time certified dietary manager for the 54 residents who resided in the facility and received their meals from the kitchen.

Inspectors wroteThe facility had a census of 54 residents. Based on observation, interview, and record review the facility failed to provide thorough infection control measures to prevent the spread or development of infection for the 54 residents of the facility when the facility failed to disinfect shared equipment between residents and failed to have a water management plan for Legionaires ( a serious type of pneumonia caused by legionella bacteria), and failed to ensure laundry temperatures were hot enough to kill bacteria. This deficient practice placed the 54 residents of the facility at risk for infection.

Inspectors wroteThe facility had census of 54 residents. The sample included 21 residents. Based on observation, record review, and interview the facility failed to provide a safe, clean comfortable and homelike environment in one of three halls in the facility and failed to provide hot water temperatures at an appropriate, comfortable temperature. This placed the residents at risk for an unsanitary, non-homelike, and uncomfortable environment.

Inspectors wroteThe facility had a census of 54 residents. The sample included 21 residents, with seven reviewed for side rails. Based on observation, record review, and interview the facility failed to educate and obtain consent for the use of a side rail and/or assessment for the safe use of side rails for for Resident (R) 7, R15, R23, R2, R16, R51 and R27. This placed the residents at risk for side rail related injuries.

Inspectors wroteThe facility had a census of 54 residents. Based on observation, interview, and record review the facility failed to label and date (when opened) two insulin (medications used to treat high blood glucose levels) pens and assess and document the medication refrigerator temperatures daily. This deficient practice placed two residents who received insulin at risk to receive ineffective insulin and placed residents who received refrigerated medications at risk for ineffective medication results.

Inspectors wroteThe facility had a census of 54 residents. The sample included 21 residents. Based on observation, record review, and interview the facility failed to maintain an effective pest control program so that the facility would be free of pests and rodents. This placed the 54 residents at risk for diseases and impaired comfort.

Inspectors wroteThe facility had a census of 54 residents. The sample included 21 residents. Based on observation, record review, and interview, the facility failed to promote care in a manner to maintain and enhance dignity and respect, when staff administered insulin (a medication used to regulate blood sugar levels) to Resident (R)30 at the [NAME] medication cart, in the hallway, with other residents in full view of the procedure.

Inspectors wroteThe facility had a census of 54 residents. The sample included 21 residents. Based on record review and interview, the facility failed to provide Resident (R)20 , or their representative, the completed Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055, and the completed Notice of Medicare Non-Coverage Form (NOMNC) Centers for Medicare and Medicare Services (CMS) form 10123, and failed to provide R7's legal guardian the 10055 and the 10123 form to sign until two days after the services ended. This placed the resident, or their representatives at risk to make uninformed decisions about their skilled services and at risk to incur charges if exercising their right to appeal.

Inspectors wroteThe facility had a census of 54 residents. The sample included 21 residents, with seven reviewed for side rails. Based on observation, record review, and interview the facility failed to update Resident (R)27's care plan for the safe use of a side rail, placing him at risk for accident or injury.

Inspectors wroteThe facility had a census of 54 residents. The sample included 21 residents, with five reviewed for nutrition. Based on observation, interview, and record review the facility failed to provide adequate supervision and assistance for Resident (R) 28 who had problems with swallowing and staff were to monitor while eating due to risk of aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident). This deficient practice placed R28 at risk for serious health issues such as pneumonia or malnutrition.

Inspectors wroteThe facility had a census of 54 residents. The sample included 21 residents. Based on observation, interview and record review, the facility failed to provide a licensed nurse with adequate competency and skills to safely administer medications. This placed Resident (R)39 at risk for medications errors.

Inspectors wroteThe facility had a census of 54 residents. The sample included 21 residents, with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to ensure blood pressures were monitored for Resident (R) 28 who received four medications which included instructions when to hold (not administer) the medication. This deficient practice placed R28 at risk for unnecessary medications and adverse effects.

Inspectors wroteThe facility had a census of 54 residents. The sample included 21 residents. Based on observation, record review and interview, the facility failed to correctly prepare a pureed diet for Resident (R)28. This placed the resident at risk for inadequate nutrition.