Deficiencies (last 4 years)
Deficiencies (over 4 years)
12 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
131% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Routine
Deficiencies: 5
Date: Jan 31, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to pharmaceutical services, nutritional services, food safety, infection prevention and control, and other care standards at Legacy Health and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including inaccurate controlled medication reconciliation, failure to prepare and serve meals according to planned menus and therapeutic diet orders, improper food storage and sanitation practices, inadequate infection prevention practices including hand hygiene and PPE use, delayed implementation of transmission-based precautions for head lice infestation, and failure to provide staff re-education despite infection trends.
Deficiencies (5)
Failed to ensure accurate account of controlled medication for 1 of 3 medication carts reviewed.
Failed to ensure meals were prepared and served according to the planned written menu to meet nutritional needs for 1 of 1 meal observed.
Failed to serve and offer double portions as ordered for 1 resident reviewed for therapeutic diet.
Failed to ensure food items were covered or sealed; ice machine not maintained clean; dietary staff failed to wash hands before handling food; kitchen had unsanitary conditions; hot food items not maintained at proper temperature.
Failed to ensure hand hygiene between residents during medication administration; improper use of PPE including reuse of dirty gown; delayed posting of transmission-based precautions for parasitic infestation; failure to provide staff re-education despite infection trends.
Report Facts
Medication cart count discrepancy: 1
Residents affected: 1
Food temperature readings: 119
Food temperature readings: 125
Food temperature readings: 126
Food temperature readings: 116
Infection counts: 4
Infection counts: 6
Infection counts: 3
Infection counts: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #9 | Licensed Practical Nurse | Named in medication reconciliation deficiency for failing to sign out controlled medication dose. |
| Director of Nursing | Director of Nursing | Provided statements regarding medication signing procedures and dietary orders. |
| Dietary Manager #1 | Dietary Manager | Interviewed regarding food preparation, meal service, and food safety deficiencies. |
| CNA #29 | Certified Nursing Assistant | Interviewed regarding failure to serve double portions to Resident #73. |
| LPN #18 | Licensed Practical Nurse | Observed failing hand hygiene and improper PPE use during medication administration. |
| LPN #25 | Licensed Practical Nurse | Reported on head lice infestation management and transmission-based precautions. |
| Infection Preventionist | Infection Preventionist | Interviewed regarding infection control practices, trends, and staff re-education. |
| Dietary DC #11 | Dietary Cook | Observed and interviewed regarding food handling and hygiene practices. |
| Dietary DC #12 | Dietary Cook | Observed handling food with contaminated gloves. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jan 31, 2025
Visit Reason
The inspection was conducted to investigate complaints related to resident-to-resident abuse, exploitation of a resident by a staff member, and safety hazards involving cleaning agents in the facility.
Complaint Details
The complaint investigation substantiated incidents of resident-to-resident physical abuse involving Resident #109 hitting Residents #68 and #84, exploitation of Resident #42 by CNA #17 who borrowed money, and a safety hazard where Resident #68 ingested a cleaning agent left within reach. The aggressor resident was placed on 1:1 supervision and later transferred. CNA #17 was terminated for policy violations. The facility conducted investigations, notified appropriate parties, and initiated staff in-services.
Findings
The facility failed to keep residents free from physical abuse by another resident, failed to prevent exploitation of a resident by a staff member who borrowed money, and failed to ensure cleaning agents were kept locked and out of reach, resulting in a resident ingesting a cleaning agent. Interventions and investigations were initiated, including staff in-services and disciplinary actions.
Deficiencies (3)
Facility failed to keep residents free from physical abuse by another resident affecting 2 residents.
Facility failed to prevent exploitation of a resident by a staff member who accepted and borrowed money from the resident.
Facility failed to ensure cleaning agents were kept locked and out of resident's reach, resulting in a resident ingesting a cleaning agent.
Report Facts
Residents reviewed for abuse: 10
Residents sampled for accidents and hazards: 6
Amount of money borrowed: 70
Incident dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #17 | Certified Nursing Assistant | Involved in exploitation of Resident #42 by borrowing money; received verbal warning and was terminated for policy violations |
| RN #13 | Registered Nurse | Assessed Resident #68 after abuse and cleaning agent ingestion incidents; reported incidents and called ambulance |
| LPN #16 | Licensed Practical Nurse | Confirmed resident-to-resident aggression and cleaning agent incident |
| Administrator | Facility Administrator and Abuse Coordinator | Notified of resident-to-resident abuse incidents and investigations |
| Director of Nursing | Director of Nursing | Confirmed resident-to-resident abuse incidents and staff interventions; involved in disciplinary actions |
Inspection Report
Routine
Deficiencies: 7
Date: Mar 21, 2024
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident dignity, care planning, medication management, safety, environment, and staff training.
Findings
The facility was found deficient in multiple areas including failure to maintain resident privacy and dignity during care, incomplete implementation of care plans for fall prevention, medication availability issues leading to missed doses, improper hand hygiene practices during incontinence care, unsafe use of restraints, unsafe resident transfers without proper safety devices, environmental maintenance deficiencies, and lack of dementia in-service training for staff.
Deficiencies (7)
Failure to ensure resident privacy and dignity by not pulling curtains or closing doors during care, exposing residents to view from hallways.
Failure to implement care plan interventions to prevent falls for a resident at risk, including improper use of restraints and lack of supervision.
Failure to ensure medications were readily available at all times for a resident on scheduled pain medication, resulting in missed doses.
Failure to perform proper hand hygiene and glove changes during incontinence care for a resident, risking infection transmission.
Failure to ensure safety devices were used during lifting and transferring of residents, increasing risk of injury.
Failure to maintain a clean, safe, and comfortable environment including damaged ceiling tiles, chipped paint, exposed nails, torn mattress vinyl, and unrepaired furniture.
Failure to provide dementia in-service training to nurse aides within the past year.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Staples protruding: 1
Medication doses missed: 2
Medication doses administered: 5
Residents on hall: 21
Showers per day: 7
Showers per day: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Discussed medication availability and documentation issues related to Resident #28 |
| ADON | Assistant Director of Nursing | Discussed medication ordering and communication failures for Resident #28 |
| DON | Director of Nursing | Provided statements on privacy, dignity, restraint use, and transfer safety |
| CNA #10 | Certified Nursing Assistant | Observed and interviewed regarding restraint use, hand hygiene, fall interventions, and privacy issues |
| CNA #11 | Certified Nursing Assistant | Discussed restraint use and staffing shortages |
| LPN #3 | Licensed Practical Nurse | Discussed fall interventions and environmental concerns |
| Maintenance | Discussed environmental repair tracking and measured protruding staples | |
| LPN #2 | Licensed Practical Nurse | Reported lack of dementia in-service training |
Inspection Report
Routine
Deficiencies: 14
Date: Mar 21, 2024
Visit Reason
The inspection was a routine regulatory survey to assess compliance with care plan implementation, fall prevention, hygiene, medication management, infection control, environmental safety, and staff training requirements.
Findings
The facility failed to implement care plan interventions for fall prevention for Resident #36, ensure individualized care plans for Residents #78 and #41, maintain safe environment and supervision for residents at risk of falls, ensure medication availability for Resident #28, maintain proper hand hygiene during incontinence care for Resident #32, maintain resident privacy during care, use safety devices during transfers for Residents #87 and #304, maintain laundry and environmental safety, and provide dementia training for staff.
Deficiencies (14)
Failed to ensure care plan interventions were implemented for Resident #36 at risk for falls.
Failed to update individualized care plan for Resident #78 regarding nail care and contracture device.
Failed to provide nail care for Resident #78 and facial hair removal for Resident #41.
Failed to provide services to minimize decline in range of motion for Resident #78 with contractures.
Failed to ensure residents at risk for falls were supervised and fall prevention interventions implemented; failed to maintain lint-free clothes dryers; failed to use gait belts during transfers for Residents #87 and #304.
Failed to ensure securement device used for Resident #68 with urinary catheter.
Failed to ensure medications were readily available at all times for Resident #28 on scheduled pain medication.
Failed to ensure staff performed hand hygiene and glove changes during incontinence care for Resident #32.
Failed to ensure Resident #36 was not restrained by locked wheelchair brakes and fall mats; failed to supervise Resident #36 properly.
Failed to maintain resident privacy during bathing and care for Residents #61, #72, and #304.
Failed to ensure safety devices were used during transfers for Residents #87 and #304.
Failed to ensure staff washed/sanitized hands during meal service and laundry workers handled clean linens properly.
Failed to maintain a clean, safe, comfortable environment in resident rooms, bathrooms, and common areas; delayed repairs of environmental hazards.
Failed to provide dementia in-service training to staff in the past year.
Report Facts
Residents affected: 1
Residents affected: 94
Residents affected: 17
Residents affected: 29
Residents affected: 11
Residents affected: 23
Lint build-up: 1
Lint build-up: 0.5
Staples protruding: 1
Ordered headboards and footboards: 10
Ordered dressers: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Discussed medication availability and documentation for Resident #28 |
| CNA #10 | Certified Nursing Assistant | Named in fall prevention and hand hygiene findings |
| CNA #11 | Certified Nursing Assistant | Named in fall prevention and hand hygiene findings |
| LPN #3 | Licensed Practical Nurse | Named in fall prevention and environmental reporting findings |
| DON | Director of Nursing | Provided explanations on restraint, fall prevention, medication, and privacy |
| ADON | Assistant Director of Nursing | Discussed medication ordering and hand hygiene |
| Maintenance | Discussed environmental repairs and hazards | |
| Laundry Aide | Discussed laundry handling practices | |
| LPN #2 | Licensed Practical Nurse | Discussed dementia training availability |
Inspection Report
Deficiencies: 1
Date: Jun 21, 2023
Visit Reason
The inspection was conducted to assess the safety, cleanliness, and comfort of the nursing home environment, specifically focusing on ensuring rooms are free of clutter to prevent injury and provide a homelike environment.
Findings
The facility failed to ensure that one of 20 rooms on the secure unit was free of clutter, with 20 boxes and 3 containers of clothes present in Room N12, creating potential fall hazards and an environment not considered homelike by staff.
Deficiencies (1)
Facility failed to ensure that 1 of 20 rooms on the secure unit was free of clutter to prevent potential injury and provide a homelike environment.
Report Facts
Rooms affected: 1
Boxes present: 20
Containers of clothes present: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Assistant #1 | Interviewed about duration and importance of clutter-free rooms | |
| Licensed Practical Nurse #1 | Interviewed about importance of clutter-free rooms | |
| Director of Nursing | Director of Nursing | Interviewed about duration of clutter and homelike environment |
| Administrator | Administrator | Interviewed about awareness of clutter and homelike environment |
| Certified Nursing Assistant #2 | Interviewed about duration and importance of clutter-free rooms |
Inspection Report
Deficiencies: 2
Date: Jun 2, 2023
Visit Reason
The inspection was conducted to assess compliance with wound care treatment orders for sampled residents, specifically focusing on whether wound care treatments were provided as ordered.
Findings
The facility failed to ensure that 2 of 4 sampled residents (Resident #2 and Resident #4) received wound care treatments as ordered. Both residents reported not receiving treatments consistently, especially on weekends, due to staffing issues.
Deficiencies (2)
Failure to provide wound care treatments as ordered for Resident #2, including missed treatments documented by 'N' indicating treatments were not completed.
Failure to provide wound care treatments as ordered for Resident #4, with multiple documented missed treatments indicated by 'N' on treatment records.
Report Facts
Residents sampled: 4
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Explained that 'N' on treatment records means treatment was not done |
| Director of Nursing | Director of Nursing | Supervised wound care and provided information about grievance and treatment monitoring |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 9, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding failure to follow physician orders for wound care and oxygen/C-PAP administration for selected residents.
Complaint Details
The investigation was complaint-driven, focusing on allegations that physician orders for wound care and oxygen/C-PAP therapy were not properly followed or documented. The complaint was substantiated based on observations, record reviews, and interviews.
Findings
The facility failed to ensure that physician orders for wound care were consistently followed for Resident #2, and that physician orders for oxygen therapy and C-PAP use were documented and followed for Resident #4. Treatment administration records showed incomplete wound care documentation and oxygen/C-PAP orders were missing despite residents receiving these therapies.
Deficiencies (2)
Failure to follow physician orders for wound care for Resident #2, including incomplete treatment administration and documentation.
Lack of physician orders for oxygen therapy and C-PAP use for Resident #4 despite resident receiving these treatments.
Report Facts
Residents in sample mix for wound care review: 4
Residents in sample mix for oxygen/C-PAP review: 2
BIMS score for Resident #2: 4
BIMS score for Resident #4: 15
Wound measurements: 10
Oxygen liters: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding wound care treatment completion and oxygen/C-PAP documentation | |
| Treatment Nurse | Interviewed regarding wound care treatment completion | |
| Director of Nursing (DON) | Interviewed regarding wound care and oxygen/C-PAP order compliance and facility policies |
Inspection Report
Routine
Census: 95
Deficiencies: 14
Date: Dec 30, 2022
Visit Reason
Routine inspection of Legacy Health and Rehabilitation Center to assess compliance with regulatory standards including resident care, environment, medication management, nutrition, and immunizations.
Findings
The facility had multiple deficiencies including failure to maintain resident dignity during meal assistance, inadequate call light accessibility, poor environmental maintenance, incomplete care plan implementation for weight loss, insufficient assistance with activities of daily living, medication administration errors, improper oxygen therapy, pain management failures, pharmacy service issues, food preparation and safety concerns, and delayed pneumococcal vaccinations.
Deficiencies (14)
Staff failed to ensure dignity during meal assistance by standing over residents and allowing a resident to eat food touched by another resident.
Call light was not placed within reach of a resident, failing to meet resident needs.
Facility failed to provide a homelike environment due to torn and unsafe furniture in the secure unit.
Care Plan interventions were not implemented to maintain nutritional status and prevent weight loss for a resident.
Assistance with activities of daily living was not provided as required, including failure to apply lotion to resident's dry skin.
Medications were left unattended and not observed to be consumed by a resident.
Oxygen was not administered at the physician ordered flow rate for a resident, resulting in hospitalization.
Pain management was inconsistent; a resident did not receive scheduled pain medication for an entire day due to pharmacy and insurance issues.
Pharmacy services failed to meet resident needs due to delayed medication refills and lack of physician notification.
Meals were not prepared and served according to the planned menu; portions of meat served were less than specified.
Food was not prepared to maintain nutritive value and appearance; pureed and regular foods were dry, burnt, discolored, and unappetizing.
Pureed food items were not blended to a smooth, lump-free consistency, posing a choking risk.
Food storage and kitchen sanitation were inadequate; food items were uncovered, undated, kitchen surfaces were dirty, and staff failed to wash hands before handling food.
Pneumococcal vaccinations were not administered timely to eligible residents despite signed consents.
Report Facts
Residents affected by dignity failure: 19
Residents affected by call light issue: 71
Residents affected by meal preparation issues: 63
Residents affected by pureed diet consistency issues: 5
Residents affected by medication left unattended: 1
Residents affected by oxygen therapy issues: 22
Residents affected by pain management failure: 21
Residents affected by food safety and sanitation issues: 89
Residents affected by pneumococcal vaccination delays: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #2 | Named in meal assistance dignity deficiency and feeding observation. | |
| Certified Nursing Assistant #6 | Named in meal assistance dignity deficiency and food contamination incident. | |
| Certified Nursing Assistant #4 | Named in meal assistance dignity deficiency and food contamination incident. | |
| Director of Nursing | Director of Nursing (DON) | Provided policy information and interviewed regarding multiple deficiencies including meal assistance, call light, weight loss, medication, and vaccination. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Named in pain medication administration deficiency. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse (LPN) | Named in pain medication administration deficiency. |
| Licensed Practical Nurse #3 | Licensed Practical Nurse (LPN) | Named in oxygen therapy and pain medication administration deficiencies. |
| Licensed Practical Nurse #4 | Licensed Practical Nurse (LPN) | Named in oxygen therapy deficiency. |
| Licensed Practical Nurse #5 | Licensed Practical Nurse (LPN) | Named in medication administration deficiency. |
| Dietary Employee #1 | Named in food preparation and sanitation deficiencies. | |
| Dietary Employee #2 | Named in food preparation and sanitation deficiencies. | |
| Dietary Employee #3 | Named in pureed food preparation deficiency. | |
| Dietary Employee #4 | Named in food preparation and sanitation deficiencies. | |
| Dietary Employee #5 | Named in food handling deficiency. | |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Provided information on vaccination delays and weight loss monitoring. |
| Administrator | Interviewed regarding vaccination delays and weight loss monitoring. |
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