Legend Oaks Healthcare and Rehabilitation Center -

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 5 resident (Resident #1) reviewed for accuracy of assessments. - The facility failed to ensure Resident #1's Quarterly MDS dated [DATE] and Discharge MDS dated [DATE] accurately reflected the residents behavior of verbally aggressive behaviors to others and resistance to care. This failures could place residents at risk of inaccurate assessments, which could compromise their plan of care .

Inspectors wroteBased on observation, interview, and record review the facility failed to administer Parenteral fluids consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 (Resident #1) residents reviewed for parenteral fluids. - RN A failed to administer Resident #1's IV antibiotic Vancomycin, a medication with known infusion rate reactions, as ordered when she administered the medication at 250 ml/hr. instead of 150 ml/hr. as ordered on by the pharmacy on 11/12/25. This failure could place residents at vancomycin infusion reactions which could result in hypotension (low blood pressure), tachycardia (fast heartrate) and cardiac arrest (when the heart suddenly stops beating).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure nurses were able to demonstrate competency in skills to provide nursing and related services for 1 of 1 resident (Resident #1) by 1 of 4 nurses (RN A) reviewed for competent staff. - The facility failed to ensure RN A was competent to administer medications via IV prior to administering medications to Resident #1 on 11/12/25 This failure could place residents at complications from IV medications and adverse reactions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from any significant medication errors for 1 of 4 residents (Residents #1) reviewed for significant medication errors. - RN A failed to administer Resident #1's IV antibiotic Vancomycin, a medication with known infusion rate reactions, as ordered when she intentionally administered the medication at 250 ml/hr. instead of 150 ml/hr. as ordered by the pharmacy. This failure could place residents at vancomycin infusion reactions which could result in hypotension (low blood pressure), tachycardia (fast heartrate) and cardiac arrest (when the heart suddenly stops beating).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, the expiration date when applicable and stored all drugs and biologicals in locked compartments and under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 4 residents ( Resident #1) reviewed for medication storage. - RN A failed to ensure Resident #1's Vancomycin IV was labeled when she administered the medication on 11/12/25. This failure could place residents at risk of incorrect medication administration and adverse reactions to medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 1 of 1 facility reviewed for required postings. - On 11/12/25 the facility failed to ensure the Direct Care Daily Staffing Numbers were updated. The postings read 11/11/25. This failure could affect residents, facility visitors, vendors, and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings Included: An observation on 11/12/25 at 08:51 AM revealed, the facility Direct Care Daily Staffing Numbers displayed on the pony wall on the left side of the front entrance. The posting read Date: 11-Nov-2025' and included the facility name, census, the scheduled hours, and staffing totals for direct care staff. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 residents (Resident #18) reviewed for comprehensive assessments. The facility failed to ensure that Resident #18's care plan documented interventions for the resident's diagnoses of acute respiratory failure with hypoxia, chronic obstructive respiratory disease, and sleep apnea to include continuous oxygen therapy and the use of BiPAP (bilevel positive airway pressure, a form of noninvasive ventilation) at bedtime. This deficient practice could place residents at risk of not receiving proper care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for one of 8 residents (Resident #18) reviewed for storage of medications. The facility failed to ensure Resident #18's Fluticasone inhaler medication used for shortness of breath, was secured, and not left at the bedside. This deficient practice could place residents at risk for loss of biologicals and place residents at risk of access to hazards.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure bulk foods were stored in a manner to prevent contamination. The facility failed to ensure foods were sealed properly in the pantry and freezer. The failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan or the residents' goals and preference for 2 of 2 residents (Resident #18 and #2) reviewed for respiratory care. -The facility failed to maintain oxygen therapy equipment in a clean and sanitary manner. Resident #18's and Resident #2's mask used with the BiPAP (bilevel positive airway pressure, a form of noninvasive ventilation) was open to air and not stored in a plastic bag. This failure could place residents at risk of infection or a decline in health.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for one (Resident #84) of four residents reviewed for pharmacy services. The facility failed to ensure all of Resident #62's medications were administered as ordered by the physician resulting the incorrect medication of Multivitamin. This failure could place residents at risk of not receiving medications as ordered by their physicians and exacerbations of their medical conditions.

Inspectors wroteBased on observation, interview, and record review 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 and transmission of communicable diseases and infections for 1 of 8 residents (Resident #18 ) reviewed for infection control practices. -The facility failed to ensure CNA-A and CNA-B followed proper infection control and hand hygiene practices during incontinent care for Resident #18. CNA-A failed to change both gloves and perform hand hygiene after cleaning the resident and prior to touching clean items. CNA-A and CNA-B failed to perform hand hygiene prior to leaving Resident #18's room after incontinent care. This failureThis failure could place residents at risk of infection or a decline in health.

Inspectors wroteBased on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 11 residents (Resident #1) reviewed for care plans. The facility failed to ensure that Resident #1's required use of hearing aids as an assistive device for her hearing impairment were documented in her care plan/[NAME]. The facility's failure placed residents requiring care at risk of not having their individual needs met, not receiving necessary care and services, and not having continuity of care.

Inspectors wroteBased on interviews, and records review, the facility failed to ensure that medical records were accurately documented for two (Resident #2 and Resident #3) of ten residents reviewed for accurate clinical records. The facility failed to ensure the hospital Nurse Report was not destroyed and included in Resident #2's permanent medical record. The facility failed to keep an accurate record of the time Resident #3 was weighed. This deficient practice could place residents at risk for errors in care and treatment.

Inspectors wroteBased on observation, interview and record review the facility failed to serve food in accordance with professional standards for food safety in one of one kitchens, in that: - The facility failed to test and maintain proper concentration level of sanitizer solution during the dishwasher's wash cycle This failure could affect all residents by placing them at risk for food-borne illness.

Inspectors wroteBased on observation , interview and record review the facility failed to develop and implement a comprehensive care plan to meet the highest practicable physical, mental, and psychosocial wellbeing for 1 (Resident #1) of 5 residents reviewed for care plans. 1. The facility failed to develop and implement a Care Plan for Resident #1's fall out of bed on 12/13/2023 and as a result, Resident #1 suffered a second fall out of bed on 4/1/2024. Resident #1 was hospitalized with a fractured hip from 12/13/2023 to 12/28/2023. Resident #1 was hospitalized from [DATE] to 4/11/2024 due to second fall on 4/1/2024. An IJ was identified on 4/18/2024. The IJ template was provided to the facility on 4/18/2024 at 5:23pm. The immediate jeopardy was determined to have been removed on 4/20/2024 due to the facilities implemented actions that corrected the non-compliance. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide supervision to prevent accidents for 1 (Resident #1) of 5 residents reviewed for accidents. The facility did not provide adequate supervision for Resident #1 while giving a bed bath on two separate occasions causing her to fall off the bed resulting in prolonged hospital stays. Resident #1 was hospitalized with a fractured hip from 12/13/2023 to 12/28/2023 after she rolled off the side of the bed during a bed bath. Resident #1 was hospitalized from [DATE] to 4/11/2024 after she rolled off the side of the bed during a bed bath. An IJ was identified on 4/18/2024. The IJ template was provided to the facility on 4/18/2024 at 5:23pm. The immediate jeopardy was determined to have been removed on 4/20/2024 due to the facilities implemented actions that corrected the non-compliance. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to develop a care plan with measurable goals, and interventions to address the care and treatment for a resident on that is on transmission-based precaution for 1 of 6 residents (Resident #36) reviewed for Care Plans. The facility failed to ensure Resident #36's transmission-based precaution was care planned. This failure could place residents at risk of needs not being met and spread of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of 1 out of 5 residents. 1. The facility failed to ensure Resident #1 was provided with opportunities to participate in activities on the weekends. These failures placed residents who desired to participate in activities on the weekends at risk of adverse effects to their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure services were provided or arranged by the facility, as outlined by the comprehensive care plan, that met professional standards of care for 1 of 18 residents (Resident #141) reviewed for services that met professional standards. The facility failed to administer blood pressure (BP) medication to Resident #141 as ordered by administering outside of parameters. This failure could place residents at risk of not receiving the care and services as ordered by their Physicians and could result in a decline in health status.