Inspection Reports for
Legacy Nursing and Rehabilitation of Franklin

The investigation was complaint-driven, focusing on residents' rights violations related to privacy and environmental conditions. The findings substantiated that Resident #49's privacy was compromised and that Residents #22 and #128 experienced inadequate environmental care.

The facility failed to protect a resident's right to privacy during showering by having multiple residents in the shower room simultaneously. Additionally, the facility failed to maintain a safe and clean environment by not honoring a resident's request for a cover sheet on a pressure reduction mattress and by not timely changing soiled bed linens for another resident.

The facility failed to obtain Certified Nursing Assistant (CNA) registry verification prior to hire for one CNA. Additionally, the facility delayed completing ordered physical therapy, occupational therapy, and speech therapy evaluations for a resident at risk for falls.

The complaint investigation found substantiated failure to assist Resident #1 with hair washing and shaving, confirmed by multiple observations and interviews with the resident, Certified Nursing Assistant, Infection Preventionist, and Director of Nursing.

The facility failed to provide proper assistance with bathing, hair washing, and shaving for Resident #1, as evidenced by observations of white flakes in the resident's hair and facial hair growth, and confirmed by interviews with the resident and staff.

The facility failed to ensure residents' rights to smoke at their leisure, respond to resident council concerns, notify physicians timely about resident conditions, protect residents from abuse, report abuse incidents properly, administer oxygen per physician orders, fully assess resident pain, maintain accurate staffing disclosures, ensure medication availability and accurate controlled substance counts, and maintain medication error rates below 5%.

The complaint investigation focused on Resident #1 leaving the facility against medical advice. The findings substantiated that the facility did not complete required documentation or discharge planning processes as mandated.

The facility failed to document that Resident #1 was informed of the risks and implications of being discharged to an unsuitable location, did not ascertain why the resident chose that location, and did not present or discuss other more appropriate discharge options. Interviews with staff confirmed the lack of documentation and inadequate discharge planning.

The facility failed to timely notify the physician and responsible party of a resident's significant change in condition, failed to implement dietitian recommendations, and did not assist a resident adequately with food and fluid intake. Additionally, medications were found unsecured at a nursing station. These deficiencies resulted in an Immediate Jeopardy situation that was later removed after corrective actions.

The investigation was triggered by complaints concerning inadequate wound care assessments and failure to complete ordered laboratory tests for residents. The complaints were substantiated based on record reviews and staff interviews confirming missing assessments and tests.

The facility failed to ensure registered nurses initially assessed residents' diabetic and pressure ulcers to deem them stable before delegating care to licensed practical nurses. Additionally, weekly wound assessments were not consistently completed, and laboratory tests ordered for a resident were not performed as required.

The complaint investigation involved abuse allegations for six residents (#25, #35, #80, #87, #94, and #416). The facility failed to protect residents from abuse, failed to report abuse timely to the state agency, and failed to conduct thorough investigations. Specific incidents included physical abuse such as choking, hitting with a shoe, and sexual abuse involving Resident #35's husband. The facility administrator did not report these incidents, citing lack of intent or cognitive impairment in some cases.

The facility failed to protect residents from abuse, failed to timely report abuse allegations to the state agency, and did not conduct thorough investigations of abuse incidents. Additionally, the facility failed to implement its abuse prevention policy and had food safety violations related to sanitizer storage and hair containment by kitchen staff.

The investigation was complaint-driven, focusing on timely physician notification of falls and follow-up care for a pancreatic mass diagnosis. The complaint was substantiated based on record reviews and staff interviews.

The facility failed to ensure timely physician notification for falls for multiple residents and did not schedule a required follow-up appointment with an oncologist for a resident with a new pancreatic mass diagnosis.

The investigation was complaint-driven, focusing on Resident #96's dietary issues and pest control concerns. The complaints were substantiated based on observations and interviews confirming the issues.

The facility failed to serve food according to Resident #96's dietary preferences related to GERD, repeatedly serving acidic foods that caused discomfort. Additionally, the facility had an ineffective pest control program, evidenced by the presence of ants in a resident's bathroom.