Legacy Village Rehabilitation

Inspectors wroteBased on interview and record review it was determined, for 1 out of 5 sampled residents, that the facility did not immediately consult with the resident's physician when there was a significant change in the resident's physical status or a need to alter treatment. Specifically, a resident experienced a change in condition after a fall and the medical provider was not notified of the change timely. This resulted in a finding of harm to the resident. Resident identifier: 2.

Inspectors wroteBased on interview and record review it was determined, for 1 out of 5 sampled residents, that the facility did not ensure residents received treatment and care in accordance with professional standards of practice. Specifically, a resident sustained a fall, experienced a change in condition and the physician was not notified. Additionally, when the physician assessed the resident the resident was sent to the emergency room where she was diagnosed with a brain bleed and passed away four days later. This resulted in a finding of harm for the resident. Resident identifier: 2.

Inspectors wroteBased on interview and record review, it was determined that for 16 of 40 sampled residents, that the facility did not electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the CMS System. Specifically, the facility did not electronically transmit 16 discharge MDS assessments to the CMS System. Resident Identifiers: 4, 10, 12, 30, 42, 46, 54, 62, 64, 68, 69, 70, 71, 72, 73, and 75. Findings Include: Minimum Data Set (MDS) Assessments and medical records were reviewed from 5/12/25 through 5/15/25 for residents 4, 10, 12, 30, 42, 46, 54, 62, 64, 68, 69, 70, 71, 72, 73, and 75. Resident 4's discharge assessment date was 1/4/25. Resident 10's discharge assessment date was 1/21/25. Resident 12's discharge assessment date was 4/7/25. Resident 30's discharge assessment date was 1/2/25. Resident 42's discharge assessment date was 1/8/25. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice. Specifically, for 1 of 40 sampled residents, the resident did not have properly labeled oxygen tubing and the humidification bottle was not being changed in a timely manner. Resident identifier: 298.

Inspectors wroteBased on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the walk-in freezer and walk-in refrigerator were open to the air.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility did not 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. Specifically, the facility was not able to provide documentation that the facility had conducted testing of the facility water supply for Legionella since 2021, there were observations of staff collecting dirty laundry in an uncovered bin that was pushed through resident hallways, and there were observations of staff not using aprons while loading soiled laundry into the washing machine. Findings Include: 1. On 5/13/25 at 8:05 AM, an interview was conducted with the Infection Preventionist (IP). [...]

Inspectors wroteBased on interview and record review, it was determined that for 3 of 40 sample residents, that the facility did not ensure that a registered nurse signed and certified that the assessment was completed. Specifically, there were three MDS assessments submitted to CMS that did not have a registered nurse signature certifying that that assessment was completed. Resident Identifiers: 90, 246, and 249. Findings Include: Minimum Data Set (MDS) Assessments and medical records were reviewed from 5/12/25 through 5/15/25 for residents 90, 246, and 249. Resident 90's entry MDS dated [DATE] did not have a Registered Nurse (RN) signature certifying that the assessment was completed. Resident 246's entry MDS dated [DATE] did not have a RN signature certifying that the assessment was completed. [...]

Inspectors wroteBased on observation and interview, it was determined, that the facility did not 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. Specifically, meal tray items were uncovered when delivered by staff throughout resident hallways. Findings Included: 1. Lunch meal trays, which included, uncovered desserts were transported through resident hallway 200. The meal cart was stationed near resident room [ROOM NUMBER]. On 8/28/23 at 1:00 PM, a Certified Nursing Assistant (CNA) was observed to carry a meal tray to resident room [ROOM NUMBER]. On 8/28/23 at 1:00 PM, a CNA was observed to carry a meal tray to resident room [ROOM NUMBER]. On 8/28/23 at 1:02 PM, a CNA was observed to carry a meal tray to resident room [ROOM NUMBER]. 2. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 2 out of 15 sampled residents, a resident's cardiac medications were not monitored according to the physician's ordered parameters and long acting insulin was held without physician's ordered parameters. In addition, the Medical Doctor (MD) was not notified per the physician's orders when a resident's blood sugar was outside of the physician's ordered parameters. Resident identifiers: 10 and 89.

Inspectors wroteBased on interview and record review it was determined, the facility did not ensure that a transfer or discharge was documented in the resident's medical record and that appropriate information was communicated to the receiving health care institution or provider. Specifically, for 2 out of 19 sampled residents, no documentation was found in the resident's medical record to indicate the basis for the transfer or that the receiving provider was provided contact information of the practitioner responsible for the resident's care, resident representative contact information, advance directive information, all special instructions for care, a discharge summary, and any other documentation necessary for a safe and effective transition of care. Resident identifiers: 8 and 22.

Inspectors wroteBased on interview and record review it was determined, for 1 out of 19 sampled residents, that each resident was not free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; excessive duration; without adequate monitoring; without adequate indication for its use; or in the presence of adverse consequences which indicated the dose should have been reduced or discontinued. Specifically, a resident was administered blood pressure medications when her blood pressure was low and a Parkinson's medication was delivered late. Resident identifier: 130.