Inspection Reports for
Legacy Nursing and Rehabilitation of Tallulah
32 CROTHERS DRIVE, TALLULAH, LA, 71282
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Inspection Report — Apr 2, 2025
Plan of Correction CMS
Date: Apr 2, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with notification requirements to residents' responsible parties regarding changes in condition and test results.
Findings
The facility failed to immediately notify the responsible party of resident #1's x-ray results in a timely manner, despite documented orders and completed imaging. The Director of Nursing confirmed the lack of timely notification.
Deficiencies (1)
F 0580: The facility failed to immediately inform resident #1's responsible party of the x-ray results for the resident's right shoulder/arm. There was no documented evidence of notification despite completed imaging and signed reports.
Report Facts
Residents reviewed: 3
Date of x-ray report signature: Mar 7, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Signed and dated the x-ray report on 03/07/2025 | |
| Director of Nursing (DON) | Confirmed resident #1's responsible party was not notified in a timely manner | |
| Administrator | Notified of the findings on 04/02/2025 |
Inspection Report — Feb 26, 2025
Routine CMS
Date: Feb 26, 2025
Visit Reason
Routine inspection of Legacy Nursing and Rehabilitation of Tallulah to assess compliance with regulatory requirements including resident care, safety, medication management, food service, and infection control.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs, timely reporting of elopement incidents, accurate assessment of safety devices, provision of adequate activities, supervision to prevent elopement, proper use and documentation of bed rails, medication monitoring, food safety and sanitation, infection control, and maintenance of kitchen equipment.
Deficiencies (10)
F 0558: The facility failed to ensure resident #144 was supplied with a call light that he could activate due to physical disabilities.
F 0609: The facility failed to timely report an elopement incident involving resident #294 to the State Survey Agency.
F 0641: The facility failed to accurately assess safety devices for effectiveness and elimination for resident #58, omitting raised edge mattress in assessment.
F 0679: The facility failed to provide adequate activities for resident #26 who was blind and not informed of activity schedules.
F 0689: The facility failed to provide adequate supervision to prevent elopement for resident #294 who exited the facility unnoticed due to a sitter error and lack of alert system on exit door.
F 0700: The facility failed to obtain physician orders, informed consent, and risk assessments for bed rail use for residents #23, #30, #34, and #60.
F 0757: The facility failed to monitor for bleeding in resident #15 receiving anticoagulant medications Eliquis and Aspirin.
F 0812: The facility failed to store, prepare, and serve food in accordance with professional standards, including dirty pots, unclean ice machine, exposed food in freezer, and bottled water stored on floor.
F 0880: The facility failed to maintain a sanitary environment by allowing employees to store personal belongings in the kitchen and storage room, risking cross contamination.
F 0908: The facility failed to maintain mechanical equipment safely, with metal shavings on the can opener and grease buildup inside the deep fryer.
Report Facts
Residents receiving meal trays: 84
Elopement risk score: 13
BIMS score: 3
BIMS score: 4
BIMS score: 15
BIMS score: 4
BIMS score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 Director of Nursing | Director of Nursing | Confirmed resident #144 could not activate call light; confirmed failure to obtain physician orders and consents for bed rails; confirmed resident #294 elopement details. |
| S7 Licensed Practical Nurse | Licensed Practical Nurse | Notified nurse of resident #294 elopement and assisted in returning resident to facility. |
| S1 Administrator | Administrator | Confirmed elopement incident and lack of alert system on exit door; notified of food service and infection control deficiencies. |
| S8 Dietary Manager | Dietary Manager | Confirmed food safety and sanitation deficiencies including dirty pots, ice machine issues, exposed food, personal belongings in kitchen, and unsafe kitchen equipment. |
| S4 Licensed Practical Nurse | Licensed Practical Nurse | Confirmed lack of documentation for bleeding monitoring for resident #15 on anticoagulants. |
| S3 Activity Director | Activity Director | Confirmed resident #26 was not informed individually of activities. |
| S6 Maintenance Supervisor | Maintenance Supervisor | Confirmed exit door lacked alert system for wander guard bracelet. |
| S5 Licensed Practical Nurse | Licensed Practical Nurse | Conducted assessments and care plan for resident #294. |
Inspection Report — Sep 16, 2024
Routine CMS
Date: Sep 16, 2024
Visit Reason
The inspection was conducted to assess compliance with care standards, including activities of daily living assistance and medication administration, at Legacy Nursing and Rehabilitation of Tallulah.
Findings
The facility failed to ensure proper personal hygiene care for a resident unable to perform activities of daily living and failed to ensure nurses followed medication orders, including insulin sliding scale and blood pressure parameters, for two residents.
Deficiencies (2)
F 0677: The facility failed to provide care and assistance for activities of daily living for a resident unable to do so, resulting in unclean feet and untrimmed nasal hair.
F 0757: The facility failed to ensure each resident's drug regimen was free from unnecessary drugs by not following blood pressure and insulin medication parameters for two residents.
Report Facts
Medication parameter noncompliance: 6
Medication parameter noncompliance: 10
Medication parameter noncompliance: 5
Medication parameter noncompliance: 14
Medication parameter noncompliance: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 Director of Nursing | Director of Nursing | Confirmed findings regarding failure to follow medication parameters and hygiene care. |
| S5 Licensed Practical Nurse | Licensed Practical Nurse | Notified of hygiene findings and confirmed medication administration errors. |
| S3 Licensed Practical Nurse | Licensed Practical Nurse | Reviewed medication administration records and confirmed medication administration errors. |
| S4 Certified Nursing Assistant | Certified Nursing Assistant | Observed resident hygiene issues and confirmed need for cleaning and grooming. |
| S1 Administrator | Administrator | Notified of all findings on 09/16/2024. |
Inspection Report — Mar 13, 2024
Routine CMS
Date: Mar 13, 2024
Visit Reason
Routine inspection to assess compliance with care standards, including treatment, nutrition, food quality, and quality assurance processes at Legacy Nursing and Rehabilitation of Tallulah.
Findings
The facility failed to provide appropriate treatment and care according to physician orders and resident care plans, maintain adequate nutritional status for residents, serve palatable and properly prepared food, and hold required quarterly Quality Assessment and Assurance meetings.
Deficiencies (4)
F684: The facility failed to turn or reposition dependent residents every 2 hours and did not administer medication as ordered for residents requiring respiratory care.
F692: The facility failed to maintain acceptable nutritional status for a resident experiencing significant weight loss and did not consistently provide ordered nutritional supplements.
F804: The facility failed to serve food that was palatable, attractive, and at a safe and appetizing temperature, with multiple residents reporting poor taste and overcooked vegetables.
F868: The facility failed to document quarterly Quality Assessment and Assurance Committee meetings as required.
Report Facts
Weight loss percentage: 11.01
Supplement doses per day: 4
Mighty shakes available: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 DON | Director of Nursing | Confirmed turning schedule for resident #50 and discussed medication administration issues for resident #345 |
| S7 LPN | Licensed Practical Nurse | Documented administration of supplements and medication doses |
| S9 DM | Dietary Manager | Reported issues with supplement availability and food quality concerns |
| S10 RD | Registered Dietician | Provided nutritional assessments and recommendations for resident #1 |
Inspection Report — Feb 5, 2024
CMS
Date: Feb 5, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food service safety standards in the kitchen environment.
Findings
The facility failed to maintain proper food storage, preparation, and cleanliness standards in the kitchen. Observations included grease buildup on equipment, improper food storage, clogged sink drains, and unsanitary conditions in refrigerators and pantry areas.
Deficiencies (5)
F 0812: The facility failed to ensure the prep table and fryer were clean and free from heavy grease buildup. The stove and stand-up oven had spills, splatters, and grease buildup.
The flour scoop was stored improperly, resting directly on the flour bin without coverage. The dry pantry floor was slippery due to cooking oil spills.
The ice machine interior contained black substance on the walls. Muffin pans and cookie sheets had grease and carbon buildup.
Food in the stand-up refrigerator was improperly labeled and included a personal staff drink. Food in the walk-in refrigerator was stored improperly with bacon over raw cabbage.
The sink drain next to the prep table was clogged, allowing old food particles to drain onto the floor with wet blankets placed nearby.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff | Interviewed regarding oven use and cleaning practices. | |
| Dietary Manager | Confirmed plumbing issues and maintenance needs. | |
| Administrator | Acknowledged kitchen issues needing correction. |
Inspection Report — Mar 15, 2023
Complaint Investigation CMS
Date: Mar 15, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding failure to provide proper Medicare beneficiary notification, inadequate assistance with activities of daily living, and improper catheter care.
Complaint Details
The investigation was complaint-driven, focusing on failure to notify residents about Medicare coverage changes, inadequate assistance with activities of daily living, and improper catheter care. The findings confirmed these issues with substantiation.
Findings
The facility failed to provide Medicare beneficiaries with required notification forms, did not ensure residents received adequate personal hygiene care including bathing and nail care, and failed to properly manage Foley catheter care to prevent urinary tract infections.
Deficiencies (3)
F 0582: The facility failed to provide the CMS Form 10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage to 3 residents discharged from Medicare Part A services with benefit days remaining.
F 0677: The facility failed to ensure 2 residents received necessary assistance with activities of daily living, resulting in unclean faces and long dirty fingernails.
F 0690: The facility failed to ensure a resident's Foley catheter bag was covered and tubing was not in direct contact with the floor, risking urinary tract infections.
Report Facts
Residents reviewed for beneficiary notification: 3
Residents reviewed for activities of daily living: 6
Residents investigated for urinary catheter: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S8MDS Coordinator | Interviewed regarding failure to send CMS-10055 forms. | |
| S9MDS Coordinator | Interviewed regarding failure to send CMS-10055 forms. | |
| S3LPN | Interviewed about Resident #2's condition and behavior. | |
| S4CNA | Interviewed about bathing schedule and Resident #2's hygiene. | |
| S5CNA | Observed bathing Resident #2. | |
| S6LPN | Confirmed Resident #13's fingernail condition. | |
| S7CNA | Confirmed Resident #13's fingernail condition. | |
| S2 Assistant Director of Nursing/Interim Director of Nursing | Confirmed Resident #13 should have received nail care. | |
| S10LPN | Notified and confirmed improper Foley catheter care for Resident #4. | |
| S11QA and Staff Development Nurse | Notified of Foley catheter care findings for Resident #4. | |
| S1 Administrator | Notified of all findings regarding beneficiary notification, ADL care, and catheter care. |
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