Inspection Reports for Legend Oaks Rehabilitation and Healthcare – Kyle

The complaint investigation was substantiated based on observation, interviews, and record review confirming Resident #2 screamed at and grabbed Resident #1's arm on 11/07/24, causing redness. The facility investigation included video review and interviews with staff and family members.

The facility failed to protect Resident #1 from physical and emotional abuse by Resident #2, who grabbed Resident #1's right arm causing redness lasting 4 days. Additionally, the facility failed to maintain an infection prevention and control program, as a medical assistant did not sanitize equipment between residents and kept personal drinks on the medication cart.

The facility was found deficient in multiple areas including failure to ensure residents wore clean clothing, incomplete advanced directives documentation, failure to respect resident privacy by knocking before entering rooms, inadequate personal hygiene and nail care for residents, failure to assist residents in obtaining dental services, improper hand hygiene by kitchen staff, and malfunctioning resident call light system.

The complaint investigation focused on the failure to report an allegation of neglect when Resident #1 was found with a steak knife and suicidal intent. The facility did not submit a self-report to the State, believing there was no actual harm. Interviews with the Director of Nursing and the Administrator confirmed the incident and the lack of reporting.

The facility failed to report an allegation of neglect to the State Agency within the required timeframe after Resident #1 was found with a knife and suicidal intent. Interviews and record reviews confirmed the incident and the facility's failure to submit a timely self-report despite the resident being hospitalized and readmitted.

The complaint involved Resident #1 being administered Chlorpromazine for agitation/PTSD without a proper diagnosis or informed consent. The family member, an RN, identified the medication was unnecessary and requested its discontinuation. The facility failed to explain the rationale or obtain valid consent prior to administration. The medication was discontinued after 6 days.

The facility failed to ensure Resident #1 was informed about his mental health diagnosis and the risks and benefits of Chlorpromazine therapy, which was administered without proper diagnosis or consent. The medication was prescribed based on incorrect assumptions, leading to unnecessary psychotropic medication use. The facility also failed to obtain valid informed consent prior to administration. The medication was discontinued after family intervention.

The facility was found deficient in multiple areas including failure to ensure valid advance directives, inadequate monitoring and care planning for residents with pacemakers, incomplete dialysis communication and coordination, failure to document vital signs prior to medication administration, improper use of psychotropic medications, failure to provide food prepared according to residents' dietary needs, improper food storage and labeling, and failure to properly dispose of garbage and refuse.

The investigation was complaint-driven based on resident and family concerns about poor food quality, incorrect meals served, insufficient dietary staffing especially on weekends, failure to follow menus, and failure to accommodate allergies and preferences. Resident council minutes documented ongoing dissatisfaction with food service.

The facility failed to provide meals according to the posted menu, particularly on 06/10/23, where residents did not receive vegetables with their meals and some were served food inconsistent with their dietary needs or preferences. Staffing shortages and lack of weekend management contributed to these issues. Several residents were served foods to which they were allergic or intolerant, and meal tickets were not consistently updated or followed. Resident council minutes reflected ongoing dissatisfaction with food quality and service.