Inspection Reports for
Nye Legacy Health & Rehabilitation Center

The complaint allegations included insufficient staffing, failure to provide bathing, failure to provide medications as ordered, and failure to ensure availability of equipment for transfers. The investigation found no concerns and the facility was in compliance with these allegations.

The complaint allegations regarding staffing, bathing, medication administration, and equipment availability were found to be unsubstantiated with the facility in compliance. However, deficiencies were identified related to resident dignity, advanced directives, PASARR screening, care plan timing and revision, hospice services, and life safety code violations including sprinkler maintenance, corridor door smoke resistance, fire drills, oxygen equipment safety, and oxygen cylinder labeling.

The complaint alleged failure to protect residents from injury, failure to provide care to prevent skin changes, failure to follow medication administration policies, and failure to follow the plan of care. Only the medication administration allegation was substantiated as non-compliant.

The facility was found to be in compliance with regulatory requirements for protecting residents from injury, providing care to prevent skin changes, and following the plan of care. However, the facility was non-compliant with medication administration policies but took appropriate corrective actions including investigation and staff training.

The facility was found to have deficiencies related to improper use of mechanical lifts risking resident injury, delayed egress door hardware requiring excessive force to release, fire door latch failures, lack of supervised carbon monoxide detectors near direct vent fireplaces, and unsecured compressed gas cylinders.

The facility failed to provide adequate ventilation for 5 resident restrooms affecting 6 residents, and the fire alarm system signal was not received by the central monitoring service, delaying emergency response. Additionally, the emergency generator lacked a remote manual stop switch.

The facility failed to provide adequate fire separation from hazardous areas, maintain 90-minute fire doors, maintain the fire alarm system according to NFPA standards, and ensure automatic sprinkler systems were in reliable operating condition. These deficiencies could allow fire and smoke to migrate throughout the facility, potentially affecting all residents, staff, and visitors.

The complaint alleged failure to ensure resident property safety from misappropriation, failure to provide care and treatment to prevent pressure sores, failure to provide interventions to protect residents from falls, and failure to provide care and treatment for bowel elimination. The facility was found compliant with property safety, fall interventions, and bowel elimination care, but deficient in preventing pressure sores.

The facility failed to provide care and treatment to prevent skin breakdown for one resident related to skin areas under a knee immobilizer, constituting a violation of Federal and State regulations. The facility ensured resident property safety and implemented interventions to protect residents from falls. No violations were found related to resident property misappropriation or fall interventions.

The complaint investigation found that Resident 1 eloped from the facility on 11/4/2013. The resident had a risk score of 7 but lacked interventions to prevent elopement. The Administrator acknowledged the lack of a security elopement bracelet and other interventions.

The facility failed to provide adequate supervision to prevent elopement for one resident who eloped on 11/4/2013. The resident had a high elopement risk score but did not have appropriate interventions such as a security elopement bracelet in place.

The complaint investigation was substantiated by findings that medications were missing for Resident 54 after an outing, and the facility failed to account for them properly.

The facility failed to account for missing medications sent with Resident 54 during an outing, including 18 Omeprazole pills and between 22-45 Hydrocodone pills. The Administrator acknowledged the issue and revised the policy for Out of Facility Medication.

The facility failed to ensure proper food temperature control before serving, with cold food items served above 41 degrees Fahrenheit, and failed to ensure separation of hazardous areas by self-closing doors and sealed penetrations. Additional deficiencies included issues with exit door accessibility, sprinkler system maintenance, fire extinguisher mounting heights, generator testing documentation, and electrical wiring compliance.