Legacy Transitional Care & Rehabilitation

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility policies titled, Infection Prevention and Control Program and Hand Hygiene and Hand-Washing Policy, the facility failed to use proper infection control measures during catheter care for one of seven sampled residents (R) (R6). This deficient practice had the potential to cause infection.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled Facility Maintenance Policy, the facility failed to ensure that three of 14 shared bedrooms on the 400 hall (rooms [ROOM NUMBER]) were maintained in good repair. Specifically, rooms [ROOM NUMBER] were not free from chipped and peeling paint, scuffed sheetrock, and damaged or broken electrical outlet.

Inspectors wroteBased on staff interviews, record review, and review of Facility policy titled, Preadmission Screening and Annual Review Policy (PASARR), the facility failed to ensure PASARR Level II was submitted for one of five residents (R) (R8). This failure had the potential to prevent R8 from attaining or maintaining the highest practicable level of mental and psychosocial well-being.

Inspectors wroteBased on observations, resident and staff interviews, and review of the facility policies titled, Call light system/Light Policy, and Facility Maintenance Policy, the facility failed to ensure that the call light communication system was functioning adequately to allow residents to call for staff assistance in two out of seven restrooms (200 hall) and two of 14 rooms (301,305) on 300 hall.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure food items in the freezer were labeled and dated and failed to discard the item by expiration date. In addition, the facility failed to maintain sanitary conditions of the ice machine in the kitchen. The deficient practices had the potential to affect all resident receiving an oral diet.

Inspectors wroteBased on observations, record review, resident and staff interviews, and review of the facility's policy titled, Language Assistance Service, the facility failed to ensure one of two sampled residents (R) (R182) with Limited English skills, was provided with resources to access and understand communications regarding his healthcare regimen.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Cleaning and Disinfection of Environmental Surface, the facility failed to maintain clean Packaged Terminal Air Conditioner (PTAC) units for seven of 56 rooms on the third and fourth floors (Rooms 223, 227, 228, 302, 316, 317 and 323). The deficient practice had the potential to compromise the health and safety of the residents by increasing the risk of infections.

Inspectors wroteBased on staff interviews, record review, and review of facility's policy titled, Residents Assessments, the facility failed to document a significant change assessment upon re-admittance and change to hospice status for one resident (R) (R 104) and failed to accurately document the discharge status for one of 64 sampled residents R192. This deficient practice had the potential to affect quality of care and resident outcomes.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Care Plan Policy and Language Access Policy: Use of Language Line Service, the facility failed to follow comprehensive person-centered care plan for one of 64 sampled residents (R) (R36). The deficient practice had the potential for R36's needs to go unmet.

Inspectors wroteBased on observations, staff interview, record review, and review of the facility policy titled, Gastrostomy Tube Feeding and Monitoring Policy, the facility failed to follow physician's orders to check residual and gastrostomy tube (G-tube) placement for one of 10 residents (R) (R 243) of ten residents receiving tube feedings. The deficient practice had the potential to cause infection, poor quality of life and negative outcomes for R243.

Inspectors wrote2. A review of the electronic medical record (EMR) for R243 revealed he was admitted to the facility with diagnoses including but not limited to gastrostomy status, acute respiratory failure, seizures, encephalopathy. Review of the most recent admission Minimum Data Set (MDS) dated [DATE] documented R423 had a Brief Interview for Mental Status (BIMS) score of 00, indicating resident was severely cognitively impaired. Review of the Care Plan for R243 revealed a care plan dated 3/12/2025 that documented the resident to Monitor/document/report to MD PRN (as needed): aspiration- fever, SOB, tube dislodged, Infection at tube site, self-extubation, Tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration. [...]

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled Dating, Labeling, and Discarding Food, the facility failed to discard food items by the expiration or use-by date, failed to discard food items with a fuzzy green substance on it, and failed to ensure dietary staff wore beard coverings while in the kitchen. The deficient practice had the potential to place the 176 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled, Administration of Medications, the facility failed to ensure one of 60 sampled residents (R) (R684) was assessed to safely self-administer medications. The deficient practice had the potential to allow access to medications otherwise not prescribed by a physician to other residents.

Inspectors wroteBased on record reviews, staff and resident interviews, and review of the facility's policy titled, Advance Beneficiary Notice Policy, the facility failed to appropriately provide the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to one of 60 sampled residents (R) (R125). This failure had the potential for R125 not to be able to express her right to make an informed choice about Medicare services as well as being provided with appeal instructions.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain a safe, clean, comfortable, homelike environment for two rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) on two of four units. Specifically, room [ROOM NUMBER] contained a circulating fan with gray substances on its blades and a privacy curtain caught in the fan blades, and room [ROOM NUMBER] had a dirty, damaged bathroom ceiling with black stains. The facility census was 181 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to attempt to obtain fingerprint checks for four of 10 files reviewed and reference checks for two of 10 employee files reviewed.

Inspectors wroteBased on observations, record review, resident and staff interviews, and review of the facility policy titled, Preadmission Screening and Annual Resident Review (PASRR) (Preadmission Screening and Resident Review), the facility failed to refer a Level Il PASRR to the appropriate state-designated authority for evaluation and determination of specialized services for one of 60 sampled residents (R) R171) reviewed with serious mental illness. The deficient practice had the potential to affect the appropriate level of care and services provided for R171.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility policy titled, Activities of Daily Living (ADLs), the facility failed to ensure that ADLs were provided for two of 60 sampled residents (R) (R65 and R154) related to nail care. Specifically, nail care was not provided for R65 and R154.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure the dumpster area was maintained in sanitary conditions. The deficient practice had the potential to attract pests and rodents and transfer harmful microorganisms to food, leading to foodborne illness.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure reusable medical equipment was cleaned between use for residents. The deficient practice had the potential lead to the spread of infection and illness. The facility census was 181 residents.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policies titled, Receiving and Storage and Service Line Refrigerated Leftover Storage, the facility failed to ensure food items were properly labeled, discard expired foods, and to ensure the inside of the ice machine was clean and free from residue. Specifically, the facility failed to ensure opened and frozen food items were properly labeled and dated and leftover food was properly covered and to ensure that kitchen equipment used for food preparation and storage was kept clean and sanitary. The deficient practice had the potential to affect 179 of 179 residents receiving an oral diet from the kitchen.

Inspectors wroteBased on observations, resident and staff interviews, the facility failed to provide a safe/clean/comfortable/homelike environment for 11 of 84 resident rooms and 10 of 48 bathrooms and for two of 66 sampled residents (R) (R128 and R428), R128 who had mobility issues from loose handrailing and R428 who had food splattered on their tube feeding pump. [...]

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, Abuse Prevention Policy, the facility failed to ensure pre-employment screening, specifically fingerprints for two of 10 staff reviewed.

Inspectors wroteBased on record review and interviews the facility failed to develop a baseline care plan for one resident (R) (R172) that included goals and interventions to meet the immediate care needs present upon admission. The deficient practice had the potential for R172 not to have care needs met.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled, Oxygen (O2) Therapy, the facility failed to provide respiratory care consistent with professional standards of practice for two of fourteen Residents (R) (R1 and R281) receiving O2 therapy, related to ensuring O2 filters were cleaned and the O2 nasal cannula (NC) was stored in a plastic bag when not in use, and failing to obtain a physician's order for O2. The deficient practice had the potential to cause respiratory distress.

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility policy titled, Administration of Medications, the facility failed to ensure the medication error rate was less than five percent (%). There were two medication errors with a total of 28 opportunities observed for two of four Residents (R) (R27 and R91) for a medication error rate of 7.14%.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Storage of Medications and Biologicals, the facility failed to properly store medication for two of 66 sampled Residents (R) (R27 and R32). This failure placed residents, staff, and visitors at risk of having unauthorized access to residents' medications.

Inspectors wroteBased on observations, staff interviews, and review of a facility document titled, Preventing Infections While Providing Personal Care and the facility policy titled, Infection Prevention and Control, Cleaning, and Disinfection of Resident-Care Items and Equipment, the facility failed to ensure staff implemented appropriate hand hygiene during the passing of trays at mealtime, before and after each resident's meal consumption for one of 66 sampled Residents (R) (R425), and failed to sanitize point of care equipment after use for two of 66 sampled Residents (R27 and R114). The deficient practice had the potential to expose residents to infection. The census was 179 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure eight of 30 sampled residents (R) (R16, R17, R19, R12, R1, R18, R30 and R22) were free from abuse. On 2/28/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy (IJ) on 2/28/2024 at 3:05 pm. The noncompliance related to the IJ was identified to have existed on 9/30/2023. An Acceptable Removal Plan was received on 3/4/2024. [...]

Inspectors wroteBased on record review, interviews, and review of the Administrator's Job Description, Administration failed to provide protective oversight of the facility environment including adequate supervision for wandering residents and failed to protect residents on the secured memory unit from an abuse free environment. This failure had the likelihood of affecting all residents residing on the secured memory unit. In addition, the facility failed to ensure that the call light communication system was functioning to alert staff that residents required assistance on one of four floors (Fourth Floor) in the facility. On 2/28/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the accuracy of the comprehensive assessment addressed the wandering behaviors for one of 30 sampled residents (R) (R1). R1's wandering led to physical altercations with multiple residents, including a physical altercation on 1/25/2024 when R1 wandered into R12's room and R12 pushed R1, causing R1 to sustain a fracture of the left elbow. On 2/28/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy (IJ) on 2/28/2024 at 3:05 pm. The noncompliance related to the IJ was identified to have existed on 9/30/2023. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment on two of four floors (Third Floor and Fourth Floor).

Inspectors wroteBased on observations, interviews, record review, the facility failed to provide Activities of Daily Living (ADL) care for eight of 30 sampled residents (R) (R4, R21, R29, R23, R25, R26, R27, and R28) related to toileting and nail care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that the call light communication system was functioning to alert staff that residents required assistance on one of four floors (Fourth Floor) in the facility.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to monitor and document behaviors for one resident (R1) who was involved in multiple resident-to-resident physical altercations due to wandering on the unit. The sample size was 30 residents.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure one resident (R8) of 30 sampled residents received adequate assistance and support from social services with receiving urgent dental services.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure one resident (R8) of 30 sampled residents received dental services timely, after multiple requests and complaints of mouth pain.

Inspectors wroteBased on observations, and resident and staff interviews, the facility failed to maintain a safe, clean, comfortable, homelike environment in twelve of 84 Residents rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) were found to have unclean conditions, broken tile, and unsafe surfaces. In addition, the third floor west and east shower room floors were unclean, and a mechanical door was left open and unlocked.

Inspectors wroteBased on observation, staff interviews, record review, and review of the facility policy titled, Administration of Medication, the facility failed to ensure medications were documented and administered for two of 35 sampled residents (R) (R 7 and R 100) according to professional standards.