Legend Oaks Healthcare And Rehabilitation Center -

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings were: 1. Record review of Resident #130's face sheet, dated 12/04/2025, revealed Resident #130 was a [AGE] year-old male and admitted to the facility 11/19/2025 with diagnoses of sepsis (the body responded improperly to an infection), Chronic obstructive pulmonary disease (common lung disease…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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.The findings included: Observation on 12/03/2025 at 10:46 a.m. revealed the [NAME] using a processor to prepare the pureed pork loin. The [NAME] had the processor sitting on one side of the counter near the 2-compartment sink with a pot of pork loin next to it. The [NAME] was observed scooping out the pork loin with a large cooking spoon and placing it in the processor to puree it. After blending the pork loin, the [NAME] reached across the 2-compartment sink grabbing the plastic liquid measuring cup which was sitting on the metal counter with liquid droplets around and near it. The [NAME] then placed the measuring cup into the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings included: Record review of Resident #16's face sheet, dated 12/04/2025, revealed the resident was a [AGE] year old female and admitted to the facility on [DATE] with diagnosis of type 2 diabetes mellitus (a condition where the body has trouble regulating blood sugar levels, leading to persistently high blood glucose levels), protein-calorie malnutrition (a nutrition status in which reduced availability of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. This deficient practice could place residents at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. The findings included: 1. Record review of Resident #226's face sheet, dated 9/26/24 revealed a [AGE] year-old male…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail for Resident #320 and failed to assess Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings included: 1. Observation on 09/24/2024 at 9:26 AM revealed there was a 5-lb. bag of shredded cheddar cheese in the reach-in cooler. The cheese was in its original package and placed in a clear, gallon-sized storage bag with a zipper-seal. The package of cheese had been opened and the zipper-sealed bag was also open. During an interview on 09/24/2024 at 9:27 AM the DS stated the zipper-sealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings included: Record review of Resident #320's face sheet, dated [DATE] revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia (a group of symptoms that affects memory, thinking, and interferes with daily life), Parkinson's disease (a movement disorder that affects the nervous system and worsens over time) without dyskinesia (uncontrolled, involuntary movements of the face, arms, and legs) without mention of fluctuations, and adult failure to thrive. Record review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. These failures could place the residents with indwelling urinary catheter devices at risk for the development of new or worsening urinary tract infections. The findings included: 1. Record review of Resident #77's face sheet, dated 9/27/24 revealed a [AGE] year-old male…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings were: 1. Record review of Resident #226's face sheet, dated 9/26/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included displacement of vascular dialysis catheter (a medical device used to access the bloodstream for dialysis treatment), end stage renal disease (condition in which the kidneys cease functioning on a permanent basis) and dependence on renal dialysis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings were: Record review of Resident #320's face sheet, dated [DATE] revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia (a group of symptoms…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings included: 1. Record review of Resident #77's face sheet, dated 9/27/24 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Record review of a face sheet dated 03/22/2024 indicated Resident #1 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included surgical wound, pleural effusion (extra fluid around the lungs), atrial fibrillation, chronic diastolic (congestive) heart failure, and adult failure to thrive. Record review of Resident #1's discharge MDS, dated [DATE], showed Resident #1's cognition was intact. Record review of Resident #1's care plan, close date 10/02/2023, revealed, the resident's dentures were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings included: 1. Record review of Resident #1's face sheet dated 03/22/2024 revealed a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included surgical wound, pleural effusion (extra fluid around the lungs), atrial fibrillation, chronic diastolic (congestive) heart failure, and adult failure to thrive. Record review of Resident #1's discharge MDS, dated [DATE], showed Resident #1's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings included: 1. Observation on 07/25/2023 at 2:55 p.m. in the reach in cooler revealed a zipper-sealed bag that was filled with cut Romaine lettuce leaves. Most of the lettuce leaves had brown parts and there was a green slimy substance at the bottom of the bag indicating some of the lettuce was in a rotten state. There was a label on the bag that read, 7/10. During an interview on 07/25/2023 at 2:56 p.m. with the DS, she stated the date on the lettuce bag was the date it was stored in the cooler. The DS agreed that the bag of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: 1. Record review of Resident's # 24 face sheet dated 7/27/23 revealed a [AGE] year-old female, admitted on [DATE] and readmitted on [DATE] with diagnoses that included: [Type 2 diabetes] condition in which your cells don't normally respond to insulin,[Heart Failure] condition in which heart muscle doesn't pump blood as well as it should and [Kidney dialysis Dependence] the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings were: Review of Resident #157's face sheet, dated 7/27/23, revealed she was admitted to the facility on [DATE] with diagnoses including Hypertensive Urgency and Type 2 Diabetes Mellitus without complications. Review of Resident #157's admission MDS assessment revealed it was completed on 7/27/23 revealed her BIMS was 3 out of 15 indicative of severe cognitive impairment. Interview on 07/28/23 at 11:39 AM the MDS Coordinator revealed a resident MDS assessment should be completed 14 days after admission. He stated Resident #157…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings were: 1. Record review of Resident #13's face sheet dated 7/26/2023 revealed the resident was an 86- year-old female who was admitted to the facility on [DATE] and had diagnoses that included: [Type 2 diabetes] condition in which your cells don't normally respond to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings were: Review of Resident #157's face sheet, dated 7/27/23, revealed she was admitted to the facility on [DATE] with diagnoses including Acute Kidney Failure, Dehydration and unspecified Dementia (range of conditions that affect the brain's ability to think, remember, and function normally). Review of Resident #157's admission MDS assessment, dated 7/27/23, revealed her BIMS was 3 out of 15 indicative of severe cognitive impairment, she required limited assistance by 1 person for transfers, was not steady and only able to stabilize and she had a fall in the last month…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings were: Record review of Resident #52's face sheet, dated 07/27/2023, revealed an original admission date of 12/02/2022, and current admission of 03/08/2023 with diagnoses that included: senile degeneration of brain (progressive loss of memory, mental abilities, and personality changes), malignant neoplasm of colon (colon cancer), Crohn's disease (chronic bowel disease that causes inflammation and irritation in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings were: Review of Resident #151's face sheet, dated 7/28/23, revealed her admission date was 7/17/23 with diagnoses including Hypertensive Urgency and Type 2 Diabetes Mellitus without complications. Further review revealed Resident #151 was skilled with QHS (Quaque [NAME] somni) waiver (a temporary exemption from a 3-day hospitalization prior to a skilled stay) and had part A (Provides inpatient/hospital coverage, skilled nursing, and hospice services), B (Provides…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.