Legend Oaks Healthcare and Rehabilitation Center -

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs for 1 of 7 Residents (Resident #3) whose records were reviewed. The facility failed to ensure Resident #3's call light was within reach so he could ask for help as needed. This deficient practice could result in residents not being able to ask for assistance as needed.

Inspectors wroteBased on interview and record review the facility failed to treat the decisions of a resident representative as the decisions of the resident to the extent delegated by the resident for 1 of 1 Resident (Resident #1) whose records were reviewed. The facility failed to provide Resident #1's representative with Resident #1's medical records per oral and written request. This deficient practice could result in the residents or family members not having access to medical records.

Inspectors wroteBased on observation, interview and record review the facility failed to respect the residents right to personal privacy and confidentiality of his or her personal and medical records including 1 of 1 Staff (OTA C) during observations of staff providing care and services. OTA C failed to lock the screen or close her laptop when she walked away from it. This deficient practice could result the resident's medical information being read by anyone walking down the hallway.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible in 1 of 4 halls (Hall 400) observed for a safe environment. Nursing staff failed to ensure the entrance of the oxygen storage room was not obstructed and that the full containers were separated from the empty containers. This deficient practice could result in oxygen cylinders being tipped over and result in a combustion or fire.

Inspectors wroteBased on observation and interview the facility failed to ensure each resident received food prepared in a form designed to meet their individual needs for 1 of 1 Resident (Resident #2) observed for a puree diet. Nursing staff failed to ensure Resident #2 received a puree diet as prescribed by his physician. On 5/12/26 he received sugar cookies with his lunch meal. This deficient practice could cause the residents to aspirate or choke and could lead to the resident's death.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were able to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility for 1 of 4 days (May 12, 2026) observed for survey results. The Administration failed to include the most recent survey results in the survey binder located in the lobby. This deficient practice could result in residents being denied reading the most current survey results.

Inspectors wroteBased on observation and interview the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers from 1 of 1 nutrition room observed for stored enteral feedings. The facility failed to ensure one box of Glucerna 1.2 containing 6 quart containers of enteral feedings did not exceed the expiration date and were removed from the nutrition room. This deficient practice could lead to residents receiving expired feedings and result in health complications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 (Resident #13 and #126) of 3 residents reviewed for incontinence care. 1. CNA-B did not clean Resident #13's pubic area and did not open the labia and thoroughly clean the vaginal area for Resident #13 during incontinence care. 2. CNA-C did not clean Resident #126's pubic area during incontinence care. This failure could place residents who required incontinence care at risk for cross contamination and the development of urinary tract infections.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents' right to self-administer medications if the interdisciplinary team has determined that this practice is clinically appropriate for 1 of 5 residents (Residents #57) reviewed for medications. MA-D gave Resident #57's Fluticasone Propionate Nasal Suspension to the resident, and the resident sprayed the medication to each nostril by himself. However, the facility did not assess and evaluate Resident #57's ability to self-administer medications and did not obtain a physician's order for self-administration of medications. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident has a right to personal privacy and confidentiality of his or her personal and medical records for 1 (Resident #86) of 29 residents reviewed the privacy of medical records. LVN-A left her computer open and unattended with Resident #86's personal and medical information on the nursing cart at the 300-hallway on 12/03/2025. This failure could place residents at risk of resident identifiable and medical information being accessed by unauthorized persons.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 resident (Resident #11) of 8 residents reviewed for MDS assessments. The facility failed to ensure Resident #11's admission 5-day MDS and Significant change MDS were coded accurately for Preadmission Screening and Resident Review (PASRR). These deficient practices could affect residents who receive care and could result in missed or inappropriate care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 7.41% based on 2 errors out of 27 opportunities, which involved two residents (Residents #57 and #18) of five residents reviewed for medication errors. 1. MA-D gave Resident #57's Fluticasone Propionate Nasal Suspension to the resident, and the resident administered two sprays to each nostril by himself, but the physician order said, Fluticasone Propionate Nasal Suspension, 1 spray in both nostrils one time a day for allergies. 2. MA-D administered 15 ml of Resident #18's Enulose Solution 10 gm/15 ml to the resident on 12/03/2025. However, the physician order indicated Enulose Solution 10 gm/15 ml, Give 30 ml by mouth two times a day for constipation. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 27 residents (Residents #130 and #81) reviewed for storage. 1. Resident #130's insulin Degludec Flex Pen for diabetes had no open date, found inside 100-wing nursing cart on 12/02/2025. 2. Resident #81's insulin Glargine Flex Pen for diabetes had no open date, found inside 100-wing nursing cart on 12/02/2025. These failures could place residents at risk of having no therapeutic effects by using old insulins.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for puree diet preparation. The facility failed to ensure dietary staff preparing the puree diets used sanitary preparation procedures. These failures could place residents who received meals and/or snacks from the kitchen at risk of food born illness.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #16) out of 27 residents reviewed for medical records. Facility nurses did not document their initials when they administered Resident #16's oxygen via a nasal cannula as ordered on the resident's medication administration record. This failure placed residents at risk for missed treatment regarding oxygen therapy as ordered which could result in decline in healing and well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 3 residents (Resident #226, Resident #221 and Resident #320) reviewed for comprehensive care plans in that: 1. The facility failed to ensure Resident #226's use of bed rails was care planned. 2. The facility failed to ensure Resident #221's use of bed rails was care planned. 3. The facility failed to ensure Resident #320's use of bed rails was care planned. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess the resident for risk of entrapment from bed rails prior to installation and review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 3 residents of 9 residents (Resident #226, Resident #221, and Resident #320) reviewed for use of side or bed rails in that: 1. The facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail for Resident #226 and failed to assess Resident #226 for risk of entrapment from bed rails before they were installed. 2. The facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail for Resident #221 and failed to assess Resident #221 for risk of entrapment from bed rails before they were installed. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. The facility failed to ensure an opened bag of shredded cheese was stored in a sealed container in the reach-in cooler. 2. The facility failed to ensure a storage bag of cooked pork was sealed and labeled with a use-by date in the reach in cooler. 3. The facility failed to store a mop in the equipment storage closet in a position that allowed air drying. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 6 residents (Resident #320) reviewed for advanced directives, in that: The facility failed to ensure Resident #320's Out-of-Hospital Do Not Resuscitate (OOH DNR) was included in the medical record and correctly completed. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 3 residents (Resident #77, and #312) reviewed for indwelling urinary catheter care. 1. The facility failed to ensure Resident #77's indwelling urinary catheter drainage bag was emptied and draining to gravity when provided with urinary catheter care. 2. The facility failed to ensure CNA C cleansed Resident #312 from the meatus (the opening of the urethra where urine exits the penis) outwards and washed the resident's scrotum, inner thighs, and thoroughly cleaned between his buttocks. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 2 of 2 residents (Resident #226, and Resident #75) reviewed for dialysis in that: The facility did not maintain communication, coordination, and collaboration with the dialysis facility for Resident #226 and Resident #75. This deficient practice could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on interview, and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 4 residents (Resident #320) reviewed for hospice services, in that: The facility failed to ensure Resident #138's most recent plan of care (POC), DNR, and hospice physician orders were available and at the facility. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.

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 disease and infection for 2 of 3 residents (Residents #77 and #312) reviewed for infection control, in that: 1. The facility failed to ensure CNA B used appropriate hand hygiene when removing her gloves after assisting Resident #77 with indwelling urinary catheter care. 2. The facility failed to ensure staff did not let Resident #312's catheter tubing touch the floor and used enhanced barrier precautions (EBP) when caring for the catheter and the resident. These deficient practices could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist residents in obtaining routine dental services to meet the needs of 1 of 2 residents (Resident #1) reviewed for dental services. The facility failed to ensure Resident #1's missing dentures were replaced. This failure could place residents at risk of not receiving needed dental care, difficulty eating, a decreased quality of life, weight loss, and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 2 of 8 residents (Residents #1 and #2) reviewed for care plans in that: Resident #1's and Resident #2's comprehensive care plan did not reflect they had dentures. This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. There was a zipper-sealed bag in the reach in cooler filled with cut lettuce leaves that were brown. 2. There was a clear plastic storage container of food thickener in the dry storage room that was not properly sealed. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for 2 of 10 residents reviewed for call light: (Resident # 24 and Resident # 158). 1. Resident # 24 call light was not placed within reach. 2. Nursing staff failed to ensure Resident #158's call light was placed within reach. This failure could place residents who used call lights for assistance at risk in maintaining and/or achieving independent functioning, dignity, and well-being.

Inspectors wroteBased on interview and record review the facility failed to conduct initially a comprehensive standardized reproducible assessment of each resident's functional capacity within 14 calendar days after admission for 1 of 6 residents (Resident #157) reviewed for comprehensive assessments. The facility failed to ensure Resident #157's comprehensive assessment was completed within 14 days. This deficient practice could place residents at risk of not having their needs met as needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive care plan was developed within 7 days after the completion of the comprehensive assessment and failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment; there was an update for 2 of 21 residents (Resident # 13 & #157) whose care plan was reviewed, in that: 1. The facility failed to update Resident #13's care plan when he started Depakote on 2/14/23. 2. The facility failed to develop Resident #157's comprehensive care plan within the required time frame. These deficient practices could place residents at risk of receiving incorrect care and cause health complications with subsequent illness.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received assistive devices to prevent accidents for 1 of 6 residents (Resident #157) reviewed for falls. The facility failed to ensure nursing staff used a gait belt when providing Resident #157 with assistance during a transfer. This deficient practice could place any resident who required assistance with transfers at risk for avoidable falls.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care and services, including oxygen administration was provided such care, consistent with professional standards of practice for 1 of 1 residents (Resident #52) reviewed for respiratory therapy in that: The facility did not obtain a signed physician's order prior to providing oxygen therapy for Resident #52. This deficient practice could affect residents who received oxygen therapy and could result in incorrect oxygen support and an increase in respiratory complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were seen by a physician at least once every 30 days for the first 90 days after admission for 1 of 6 residents (Residents #51) whose care was reviewed. Physician K did not conduct an initial visit with Resident #151 within the first 30 days after admission. This deficient practice could place any newly admitted residents at risk for not having their physician visit completed in a timely manner and could lead to a decline in health status or untreated conditions.