Legend Oaks Healthcare and Rehabilitation - New Br

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 3 of 7 (Resident #11, #32, and #92) residents reviewed for respiratory care. 1. The facility failed to ensure Resident #11's oxygen was administered at the correct setting of 5 liters per minute on 05/20/2026 as ordered by the physician. 2. The facility failed to ensure Resident #32's oxygen concentrator had a clean filter on 5/17/2026. 3. The facility failed to ensure Resident #92's oxygen concentrator had a clean filter on 5/17/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #123) of 4 residents reviewed for baseline care plans. The facility failed to include Resident #123's ileostomy care, oxygen care, and wound care in his baseline care plan. This failure could result in residents not receiving needed care and treatment. [...]

Inspectors wroteBased on observations, interviews, and record review, 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 1 of 6 medication carts (200/300-hall medication aide cart) reviewed for pharmacy services. The facility failed to ensure one bottle of medication (Simethicone 125 mg for gas relief) that expired on 03/2026 was not on 200 and 300-hall medication aide cart on 05/18/2026. 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 all drugs and biologicals were stored in locked compartments for 1 (200 /300-hall Nurse Cart) of 6 medication carts and 1 (Resident #123) of 28 residents reviewed for storage and medication carts. 1. The narcotic box inside 200 and 300-hall nursing cart was totally taken out from the cart without affixing permanently to the cart. 2. There were two bottles of Curad Plain Packing Strip for wound care (it used for boils, abscess, or other draining wounds) on the resident's nightstand unattended. This failure could place residents at risk of misappropriation of medications and using packing strip for wound care to different purpose, such as eating it.

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. The facility failed to ensure that 4 bags of gravy mix located in the dry storage room were labeled and dated when they were received. This failure 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 enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 2 (Resident #11 and #43) of 28 residents reviewed, in that: 1. Resident #11's personal refrigerator located in his room was observed on 05/17/2026, and there were one piece of cake, sandwich, and one cup of milk inside the refrigerator, but no date on the food. 2. Resident #43's personal refrigerator located in her room was observed on 05/17/2026, and there was melting ice cream inside the refrigerator, instead of freezer area, but no date on it. This deficient practice could place residents at risk of foodborne illness due to consuming foods which might be spoiled.

Inspectors wroteThe facility failed to ensure that the garbage and refuse containers were in good condition (no leaks) and is waste properly contained in dumpsters or compactors with lids or otherwise covered and that the garbage storage area was well maintained in a sanitary condition to prevent the harborage and feeding of pests for 1 of 1 garbage disposal area reviewed. The facility failed to keep the area around the outdoor garbage receptacle clear of debris when a bag of trash and broken-down boxes were observed outside the garbage receptacle and on the ground. The facility failed to keep the lids closed on the outdoor garbage receptacle during observation of the garbage receptacles. These failures could cause unpleasant odors and attract pest and rodents to the facility. During an observation and interview on 5/17/2026 at 9:55AM revealed, the dumpster outside was in an enclosed area. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure all drugs and biologicals were locked in compartments under proper temperature controls and permitted only authorized personnel to have access to the keys, for 1 of 6 medication carts (the 400-hall medication cart) reviewed for security. LVN B left the 400-hall medication cart unsupervised, unattended, and unlocked for more than 9 minutes on 4/28/2026. This failure could place residents at risk for misappropriation of property and or not receiving the therapeutic effects of their medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food that was palatable to meet the needs of each resident for 3 of 5 residents (Resident #2, #3 and #4), reviewed for Dining services in that:The facility failed to provide food that was palatable in that residents were given burnt food during meal. This failure could place residents who ate foods from the kitchen at risk of a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to implement COVID-19 immunizations policies and procedures to ensure that resident's medical record includes documentation that indicates that the resident or resident representative was offered provided education regarding the benefits and potential risks associated with COVID-19 vaccine for 1 of 5 (#1) residents reviewed for COVID-19 vaccination status in that:The facility failed to provide documentation that Residents #1 had received education regarding the benefits and potential risks associated with COVID-19 vaccine. These failures placed residents at risk for not being informed/educated about immunization and decline in health status. infections, the transmission of infectious disease, and a decline in health status.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who need respiratory care were provided such care, consistent with professional standards of practice for 3 of 6 residents (Residents #76, #85 and #252) were reviewed for respiratory care. 1. Nursing staff failed to clean the oxygen concentrator regularly for Resident #76. 2. Nursing staff failed to clean the oxygen concentrator regularly for Resident #85. 3. Facility failed to ensure Resident #252 had physician orders for oxygen that was observed being used on 03/25/2025 and 03/26/2025. This failure could place residents at risk of illness and respiratory complications.

Inspectors wroteBased on interview and record review 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 1 of 5 residents (Resident #43), reviewed for pharmacy services. The facility did not have Resident #43's ordered PRN (as needed) hydrocodone (pain medication) available for 9 days from his admission on [DATE] to his discharge on [DATE]. This failure could place the residents at risk of pain and not receiving needed care and services.

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. The facility failed to ensure dietary staff used proper hand placement and hand hygiene during plate preparation. The facility failed to ensure a divided plate was properly dried prior to serving a grilled cheese sandwich in it. This failure 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 ensure the assessment accurately reflect the resident's status for 2 of 8 Residents (Resident #76 and Resident #85) whose records were reviewed. 1. Nursing staff failed to code that Resident #76 was diagnosed with Depression on his annual assessment, dated 2/2/25. 2. Nursing staff failed to code that Resident #85 received oxygen therapy on her annual assessment, dated 2/4/25. This deficient practice could affect any resident and contribute to residents not receiving care and services as needed.

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 timeframe's to meet a resident's medical and nursing needs for 2 of 8 Residents (Resident #85 and #92) whose records were reviewed. 1. Nursing staff failed to include Resident #85 used side rails for repositioning and mobility on the comprehensive Care Plan, dated 2/4/25 2. Nursing staff failed to include Resident #92 used side rails for repositioning and mobility on the comprehensive Care Plan, dated 2/24/25. This deficient practice could affect any resident and result in resident's not receiving care and services as needed.

Inspectors wroteBased on observation, interview and record review revealed based on a resident's comprehensive assessment, the facility must ensure that a resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 8 Residents (Resident #95) whose records were reviewed for weight loss. Nursing staff failed to follow physician orders to weigh Resident #95 weekly for four weeks and then failed to implement dietary interventions once his weight started trending down. This deficient practice could affect residents at risk for losing weight and result in unplanned weight loss and a decline in the resident's overall health.

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; review the risks and benefits of bed rails with the resident or resident representative for 2 of 8 residents (Resident #85 and Resident 95) whose records were reviewed. Nursing staff failed to assess Resident #85 and Resident #95 for the use of side rails, discuss the risks versus benefits of using side rails with the resident and or representative upon admission. This deficient practice could affect residents who used side rails and could contribute to avoidable injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were secured properly within 2 of 4 medication carts (med cart in hall 300 and med cart in hall 400) observed for medication storage. One unidentified small round white pill was observed in the bottom drawer of the medication cart on 400 hall. Two unidentified small round white pills were observed in the top drawer of the medication cart on 300 hall. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications as ordered.

Inspectors wroteBased on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 1 (Cook D) of 28 employees reviewed for training requirements. The facility failed to implement and maintain a training program that ensured [NAME] D received required trainings upon hire and annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory effective communications training for 1 (Cook D) of 28 employees reviewed for training. The facility failed to ensure effective communication training was provided to [NAME] D annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory training on Dementia management training for 1 (Cook D) of 28 employees reviewed for training. The facility failed to ensure Dementia management training was provided to [NAME] D annually. This failure could place residents at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on interview and record review the facility failed to include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of it's QAPI program for 1 (Cook D) of 28 employees reviewed for training requirements. The facility failed to ensure required QAPI trainings was provided to [NAME] D annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on interview and record review, the facility failed to include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program for 1 (Cook D) of 28 employees reviewed for training. The facility failed to ensure standards, policies, and procedures for an infection prevention and control program training was provided [NAME] D annually. This failure could place residents at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory ethics training for 1 (Cook D) of 28 employees reviewed for training. The facility failed to ensure ethics training was provided to [NAME] D annually. This failure could place residents at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide behavioral health training consistent with the requirements at §483.40 and as determined by the facility assessment at §483.71 for 1 (Cook D) of 28 employees reviewed for training. The facility failed to ensure behavioral health training was provided to [NAME] D annually. This failure could place residents at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident's right to be free from misappropriation of resident property for 2 of 3 residents (Residents #2 and #3), reviewed for drug diversion in that: 1. After Resident #2 was discharged from facility on 8/1/2024, the facility failed to remove Resident #2's medication blister pack of Hydrocodone/acetaminophen 10-325mg (a combination opioid pain medication used for treating moderate to severe pain, also referred to as Norco) and its corresponding count card from the medication cart, resulting in 8 tablets of this narcotic pain medication being available to be diverted by RN- B for her own personal use. 2. The facility failed to prevent the misappropriation of 5 tablets of Resident #3's Hydrocodone/Acetaminophen 7.5-325mg from being diverted by RN-B for her own personal use. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to review and revise resident care plans after each assessment for 1 of 5 residents (Resident #4) reviewed for care plan revision/timing. The facility failed to ensure Resident #4's care plan addressed changes in her bowel incontinence and subsequent increase in risk for skin breakdown. This deficient practice could affect residents' care and services and may cause a delay in treatment and/or decline in health.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents who need respiratory care were provided such care, consistent with professional standards of practice for 1 of 2 residents (Resident #1) reviewed for respiratory care. Facility failed to ensure Resident # 1 received respiratory therapy as ordered. This facility could result in residents receiving inadequate treatment.

Inspectors wroteBased on interviews and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 3 residents (Resident #3) reviewed for accuracy of records, in that: The facility failed to ensure the medication administration records (MAR) for Resident #3 accurately reflected the administration of her PRN medication Hydrocodone-Acetaminophen (also known as Norco) on 5 different administrations in February and March 2024. This failure could put residents at risk of improper medication administration based on inaccurate documentation and prevent accurate tracking of residents' condition and need for pain management.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 7 Residents (Resident #2) reviewed for treatments and services. The facility failed to ensure Resident #2 received dressing changes to the abrasion on her arm every Monday, Wednesday and Friday as ordered by physician. This failure could affect residents with wound dressings and place them at risk for infection.

Inspectors wroteBased on observation,s, interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #2) of 7 residents reviewed for accuracy and completeness of clinical records. The facility failed to accurately document Resident #2' s wound care status in her treatment administration record. Resident #2's wound care to her right elbow was documented as completed when it had not been provided to the resident. This failure placed facility residents at risk for lack of wound care or incorrect wound care due to misinformation by incomplete and inaccurate medical record.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary care and services to a resident who is unable to carry out activities of daily for 1 of 7 residents (Resident #2), reviewed for activities of daily living in the area of toileting in that: Resident #2 was not provided with incontinent care by a nursing staff member on 2/7/24 and 2/8/24 for up to a period of eight hours each day. This failure could result in residents experiencing a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure an allegation of neglect was reported immediately, but not later than 2 hours after the allegation was made, when the events that caused the allegation involved neglect for 1 of 8 Residents (Resident #48) whose records were reviewed for neglect. The ADM failed to report an allegation of neglect to the State Survey Agency within 2 hours after Resident #48 fell backwards in his wheelchair during transport to Dialysis. This deficient practice could affect any resident and contribute to further resident neglect.

Inspectors wroteBased on interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman of the transfer or discharge and the reasons for the transfer or discharge in writing for 1 of 3 residents (Residents # 103) resident reviewed for transfer and discharge. The facility initiated a discharge for Resident #103 due to a change of condition and did not notify the State Long-Term Care Ombudsman by phone or in writing. This failure could place residents at risk of improper discharge planning and diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to conduct a periodic comprehensive assessment of each resident's functional capacity for 1 of 8 Residents (Resident #42) whose records were reviewed for assessments. MDS staff failed to assess Resident #42 for activity preferences on her annual MDS. This deficient practice could affect any resident and could result in the assessment being incomplete and or not reflecting a complete pictures of the resident's activity preferences.

Inspectors wroteBased on interview and record review the facility failed to ensure the physician acted upon and documented his or her rationale in the resident's medical record to the pharmacist report of any irregularities for 1 of 8 Residents (Resident #42) whose records were reviewed for psychotropic use. The facility failed to ensure the physician provided a rationale in response to the pharmacist recommendation to evaluate the effectiveness and continued use of Remeron an appetite stimulant (antidepressant) for Resident #42. This deficient practice could affect any resident and could result in resident's receiving psychotropic medications longer than required.

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 in the facility's only kitchen. The Dietary Manager and [NAME] A failed to wear beard restraints while working in the kitchen. This failure could place residents who receive food prepared in the facility's only kitchen by placing them at risk for food-borne illness and food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 6 (Resident #4) reviewed for respiratory care. Resident #4's PRN oxygen was set at 0.5 L rather than the physician's order for 1-3 L. This failure could affect residents administered oxygen and could lead to residents not receiving the therapeutic effects of oxygen; and could lead to a diminished quality of life.