Inspection Reports for
Legacy Nursing and Rehabilitation of Winnsboro
804 POLK STREET, WINNSBORO, LA, 71295
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Inspection Report — Jul 9, 2025
Routine CMS
Date: Jul 9, 2025
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, environment, medication administration, and facility operations.
Findings
The facility was found deficient in multiple areas including resident dignity and hygiene, environmental cleanliness, timely completion of assessments, respiratory care, medication administration errors, food storage and sanitation, and maintenance of equipment safety.
Deficiencies (11)
F 0550: The facility failed to treat Resident #76 with dignity and respect by not providing bed linens, exposing the resident's brief and failing to maintain privacy.
F 0584: The facility failed to maintain a safe, clean, and homelike environment for multiple residents, including dirty rooms, damaged wheelchairs, and unsanitary laundry conditions.
F 0628: The facility failed to complete a discharge summary for Resident #89 as required by policy.
F 0640: The facility failed to complete and transmit Minimum Data Set (MDS) assessments timely for four residents.
F 0677: The facility failed to provide necessary assistance for activities of daily living, resulting in poor personal hygiene for Residents #11 and #22.
F 0688: The facility failed to provide appropriate care to maintain or improve range of motion for Resident #1 by not providing prescribed hand rolls and elbow splint.
F 0689: The facility failed to ensure Resident #5's environment was free from accident hazards by not securing bed rails properly.
F 0695: The facility failed to provide safe and appropriate respiratory care for Residents #1, #5, and #22, including unclean oxygen concentrators, incorrect oxygen flow, and untimely nebulizer tubing changes.
F 0759: The facility had a medication error rate of 5.41%, with two errors observed during medication administration for Resident #72.
F 0812: The facility failed to store food properly and maintain sanitary conditions in the kitchen, including dirty equipment, expired or unlabeled food items, and grime buildup.
F 0908: The facility failed to maintain electrical equipment safely, with exposed wires found on Resident #70's bed control.
Report Facts
Medication error rate: 5.41
Medication errors: 2
Medication administration opportunities: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 Director of Nursing | Director of Nursing | Interviewed and notified about multiple deficiencies including dignity, hygiene, respiratory care, and medication errors |
| S4 Licensed Practical Nurse | Licensed Practical Nurse | Administered medications with errors for Resident #72 |
| S15 Maintenance Supervisor | Maintenance Supervisor | Confirmed loose bed rails and exposed wires on bed control |
| S14 Dietary Manager | Dietary Manager | Confirmed unsanitary kitchen conditions and improper food storage |
| S3 Licensed Practical Nurse | Licensed Practical Nurse | Confirmed Resident #1's lack of splints and unclean oxygen concentrator |
| S6 Certified Nursing Assistant | Certified Nursing Assistant | Confirmed Resident #1's oxygen concentrator condition and lack of splints |
Inspection Report — Nov 14, 2024
Complaint Investigation CMS
Date: Nov 14, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding nursing staff competency and documentation of wound care for residents.
Complaint Details
The investigation was complaint-driven, focusing on nursing staff competency and wound care documentation. The deficiencies were substantiated based on record reviews and interviews.
Findings
The facility failed to ensure nursing staff demonstrated competency in wound care and did not document wound care as ordered for two residents on multiple dates.
Deficiencies (2)
F 0726: The facility failed to ensure nursing staff competency in wound care and did not document wound care for resident #1 on 10/25/2024, 10/27/2024, and 11/04/2024 as ordered.
F 0726: The facility failed to document wound care for resident #2 on 10/31/2024 as ordered, indicating a lack of proper nursing documentation.
Report Facts
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Interviewed regarding lack of wound care documentation |
Inspection Report — May 15, 2024
Annual Inspection CMS
Date: May 15, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care, including resident care, safety, and medication management.
Findings
The facility was found deficient in multiple areas including failure to provide adequate assistance with activities of daily living and personal hygiene, inadequate supervision to prevent falls, failure to provide appropriate catheter care and justification, failure to maintain nutritional status, improper respiratory care equipment storage, lack of nursing staff competency regarding catheter use justification, and failure to monitor a resident on anticoagulant medication for bleeding.
Deficiencies (8)
F 0677: The facility failed to provide necessary assistance with activities of daily living and personal hygiene for residents #51, #55, and #57, including failure to change soiled clothing and trim nails.
F 0689: The facility failed to ensure a safe environment and adequate supervision to prevent falls for resident #51, who was observed ambulating unassisted and barefooted despite high fall risk.
F 0690: The facility failed to provide appropriate catheter care and failed to assess medical justification for urinary catheter use for resident #9, resulting in urinary tract infections and actual harm.
F 0692: The facility failed to provide adequate nutritional support and assistance with meals for resident #51, resulting in significant weight loss and inadequate meal consumption.
F 0695: The facility failed to properly store oxygen tubing and nasal cannula for resident #10 when not in use, contrary to policy.
F 0726: The facility failed to ensure nursing staff competency regarding the need for medical justification for urinary catheter use for resident #9.
F 0756: The facility failed to ensure the pharmacist performed monthly drug regimen review and failed to identify lack of monitoring for bleeding in resident #30 receiving anticoagulant medication.
F 0757: The facility failed to ensure resident #30's drug regimen was free from unnecessary drugs by not monitoring for bleeding while on anticoagulant therapy.
Report Facts
Weight loss percentage: 11.66
Fall risk score: 65
Urinary tract infection treatment duration: 5
BIMS scores: 1
BIMS scores: 6
BIMS scores: 13
BIMS scores: 10
BIMS scores: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 Director of Nursing | Director of Nursing | Confirmed staff responsibilities and deficiencies related to resident care and catheter justification |
| S12 Licensed Practical Nurse | LPN / Minimum Data Set Coordinator | Acknowledged lack of catheter justification awareness for resident #9 |
| S13 Nurse Practitioner | Nurse Practitioner | Confirmed no medical justification for urinary catheter for resident #9 and ordered catheter removal |
| S7 CNA Supervisor | CNA Supervisor | Confirmed resident #51 required total assistance with meals and ambulation |
| S11 Licensed Practical Nurse | Licensed Practical Nurse | Reported urinary catheter care and infection management for resident #9 |
| S14 Licensed Practical Nurse | Licensed Practical Nurse | Confirmed nasal cannula storage policy for resident #10 |
| S10 Certified Nursing Assistant | Certified Nursing Assistant | Observed resident #51 vomiting and meal assistance needs |
Inspection Report — May 7, 2024
Routine CMS
Date: May 7, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with wound care and pressure ulcer treatment standards, including review of wound care orders, treatment administration, and nursing competencies related to resident care.
Findings
The facility failed to provide wound care as ordered for 2 of 4 residents reviewed, experienced delays in initiating antibiotic therapy for infected wounds, and nursing staff failed to timely communicate wound culture results and progress notes for residents. These deficiencies resulted in minimal harm or potential for actual harm to residents.
Deficiencies (3)
F684: The facility failed to provide appropriate wound care as ordered for 2 of 4 residents reviewed, including delays in changing wound care orders and inconsistent treatment documentation.
F686: The facility failed to provide appropriate pressure ulcer care and delayed initiation of antibiotic therapy for 1 of 3 residents reviewed, resulting in wound deterioration and infection.
F726: The facility failed to ensure nursing staff had appropriate competencies, including timely communication of wound culture results and progress notes for 2 of 4 residents reviewed.
Report Facts
Wound measurements: 4
Wound measurements: 6.5
Wound measurements: 0.9
Wound measurements: 4.2
Wound measurements: 3.4
Wound measurements: 0.1
Wound measurements: 4
Wound measurements: 4.5
Wound measurements: 0.7
Medication dosage: 500
Medication dosage: 10
Medication duration: 14
Medication duration: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3 Licensed Practical Nurse | Treatment Nurse | Named in interviews regarding wound care order changes and treatment documentation |
| S5 Nurse Practitioner | Nurse Practitioner | Named in wound care assessments, progress notes, and culture orders |
| S4 Registered Nurse | Treatment Nurse | Named in interviews confirming wound care order changes and receipt of progress notes |
| S2 Director of Nursing | Director of Nursing | Named in interviews confirming delays in receipt of wound culture results and progress notes |
Inspection Report — Feb 15, 2024
Complaint Investigation CMS
Date: Feb 15, 2024
Visit Reason
The inspection was conducted following complaints and allegations of abuse, neglect, and failure to report suspected abuse involving multiple residents at the facility.
Complaint Details
The complaint investigation involved four sampled residents (#1, #4, #5, and #7). Resident #7 was physically and verbally abused by a CNA on 02/13/2024, which was witnessed by licensed nurses. Resident #1 was involved in an incident where the Administrator allegedly kicked the resident after the resident became combative and bit the Administrator. Staff failed to report this abuse as required. The facility also failed to perform a body audit after resident #1 fell from a wheelchair.
Findings
The facility failed to protect residents from physical and verbal abuse by staff, failed to timely report suspected abuse, and failed to ensure licensed nurses performed appropriate assessments after resident falls. Specific incidents involved abusive behavior by a CNA toward a cognitively impaired resident and failure to report and properly assess injuries after a resident fell from a wheelchair.
Deficiencies (3)
F 0600: The facility failed to protect residents from physical and verbal abuse by staff, resulting in actual harm to one resident who was aggressively handled and verbally abused by a CNA.
F 0609: The facility failed to timely report suspected abuse and ensure all alleged violations involving abuse, neglect, or exploitation were reported immediately to proper authorities.
F 0726: The facility failed to ensure licensed nurses performed a body audit after a resident fell from a wheelchair to the floor, risking undetected injuries.
Report Facts
Residents sampled: 4
Date of abuse incident: Feb 13, 2024
Date of report completion: Feb 15, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | CNA (S3) was witnessed being physically and verbally abusive to resident #7 and was terminated immediately. | |
| Licensed Practical Nurse (LPN) | Two LPNs (S5 and S6) witnessed the abuse of resident #7 by the CNA and reported it to the Director of Nursing and Administrator. | |
| Director of Nursing (DON) | S2DON was notified of the abuse incident and confirmed the CNA was terminated immediately. | |
| Administrator | S1Administrator was notified of the abuse incident and confirmed the CNA was terminated immediately. Also involved in an incident with resident #1. | |
| Family Nurse Practitioner (FNP) | S4FNP was involved in the termination process of the abusive CNA and confirmed no injuries were noted on resident #7. |
Inspection Report — Aug 17, 2023
Complaint Investigation CMS
Date: Aug 17, 2023
Visit Reason
The inspection was conducted following a complaint regarding inadequate supervision and improper transfer techniques that resulted in a resident injury.
Complaint Details
The complaint was substantiated as the facility failed to follow its transfer policies, leading to a resident injury. The CNA involved was disciplined and retrained.
Findings
The facility failed to ensure adequate supervision and proper use of assistance devices during resident transfers, resulting in an actual harm injury to one resident. Corrective actions including staff training and monitoring were implemented prior to the investigation.
Deficiencies (1)
F 0689: The facility failed to ensure a resident received adequate supervision and assistance devices during transfer, resulting in a left hip fracture. The CNA did not use the required two-person transfer or mechanical lift as per the care plan.
Report Facts
Residents sampled: 5
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Involved in improper transfer causing resident injury; identified as S4CNA | |
| Licensed Practical Nurse (LPN)/CNA supervisor | Interviewed regarding the incident and resident assessment; identified as S3LPN | |
| Director of Nursing | Confirmed transfer requirements and facility policies; identified as S2DON |
Inspection Report — Jun 28, 2023
Complaint Investigation CMS
Date: Jun 28, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding improper storage of medications in the facility.
Complaint Details
The visit was complaint-related concerning medication storage. The deficiency was substantiated as the medication was found unsecured contrary to orders.
Findings
The facility failed to ensure that all drugs and biologicals were stored in locked compartments as required. Specifically, medications were found unsecured on a resident's bedside table contrary to physician orders and facility policy.
Deficiencies (1)
F 0761: The facility failed to store drugs and biologicals in locked compartments for one resident who had medications stored in their room. Observation revealed multiple tubes of Voltaren gel on the resident's bedside table despite orders requiring storage in the medication cart.
Report Facts
Number of residents affected: 1
Number of tubes of Voltaren gel observed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding medication storage policy and findings. |
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