Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Legend Oaks Healthcare And Rehabilitation Center - during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of combative, resistant, and wandering behaviors was inaccurately assessed in the MDS, which failed to document these behaviors despite clear evidence in the care plan and staff observations. Staff interviews confirmed frequent resistance to care and attempts to elope, but the MDS assessments indicated no such behaviors, contrary to facility policy requiring accurate and comprehensive assessments.
A nurse administered IV Vancomycin to a resident at a rate higher than ordered and without a proper pharmacy label, despite knowing the correct infusion rate and lacking an IV pump. The resident, who had multiple medical conditions and impaired cognition, received the medication at 250 ml/hr instead of the prescribed 150 ml/hr. Facility staff confirmed that the medication should have been given at the ordered rate using a pump and with complete labeling, as required by policy.
A nurse administered IV Vancomycin to a resident at a rate faster than ordered, without demonstrating competency in IV medication administration or the use of dial-a-flow tubing. The nurse had not received training or a skills assessment for IV medications, did not follow instructions to wait for a pump, and failed to assess the resident for adverse reactions. The IV bag was also missing a required pharmacy label, and facility policy on nurse competency and medication administration was not followed.
A significant medication error occurred when a nurse intentionally administered IV Vancomycin at a faster rate than ordered, without using a medication pump and without proper training or assessment. The resident, who had multiple health conditions and severe cognitive impairment, received the medication at 250 ml/hr instead of the prescribed 150 ml/hr. The nurse did not follow facility policy for medication administration or error reporting, and the incident was not immediately managed according to established procedures.
A registered nurse failed to ensure an IV Vancomycin medication was properly labeled before administration to a resident with multiple medical conditions and severe cognitive impairment. The IV bag lacked a pharmacy label with required information, contrary to facility policy and professional standards, as confirmed by staff and record review.
The facility did not update and post the required daily direct care staffing information in a timely manner, resulting in outdated staffing numbers being displayed in public areas. The Staffing Coordinator, responsible for this task, was delayed due to assisting residents and had not received training on the posting requirements. Both the Administrator and Staffing Coordinator acknowledged the importance of timely updates to prevent confusion for residents and visitors.
A resident with acute respiratory failure, COPD, and sleep apnea did not have their care plan updated to include required oxygen therapy and BiPAP use, despite having physician orders and receiving these treatments. The care plan only addressed fall risk and pain, omitting critical respiratory interventions. Staff interviews confirmed the omission and acknowledged the care plan should have included these needs.
A resident with respiratory and cardiac conditions was found to have a Fluticasone inhaler left unsecured on the nightstand, despite no physician order or assessment for self-administration. Staff interviews confirmed that medications should not be left in resident rooms without proper authorization, and facility policy requires all drugs to be stored in locked compartments. The incident was inconsistent with both facility policy and regulatory standards.
Surveyors found that kitchen staff failed to properly seal and store bulk foods, including dry noodles and frozen items, leaving them exposed to air and potential contamination. The Dietary Manager confirmed that food should be sealed and labeled according to facility policy, but was unaware of who was responsible for the lapse.
Two residents requiring BiPAP and oxygen therapy did not have their respiratory masks stored in plastic bags when not in use, leaving the equipment exposed on nightstands or draped over ventilators. Staff interviews confirmed knowledge of the proper storage procedure, and facility policies required masks and cannulas to be kept clean and covered. Despite this, infection control practices were not followed, resulting in a deficiency related to the safe and sanitary management of respiratory care equipment.
A resident with multiple chronic conditions was given a multivitamin with minerals instead of the physician-ordered multivitamin. Staff interviews confirmed the error and highlighted the importance of following medication administration protocols, including verifying medication orders and labels, which were not adhered to in this case.
During incontinent care, two CNAs did not follow proper infection control protocols by failing to change gloves and perform hand hygiene after cleaning a resident and before handling clean items. One CNA used a gloved hand exposed to contaminated areas to touch clean briefs and bedding, and both CNAs did not sanitize their hands before leaving the room. The resident required substantial assistance due to multiple health conditions, and staff interviews revealed inconsistent understanding of infection control procedures despite documented in-service training.
A resident with moderate cognitive impairment and hearing impairment did not have her use of hearing aids documented in her care plan, leading to confusion among staff and potential communication difficulties. The facility's policy on care planning was not followed, and the resident's family reported concerns about the facility's assistance with hearing aids, including a period when they were lost.
The facility failed to maintain accurate medical records for two residents, leading to potential errors in care. A resident's hospital Nurse Report was shredded instead of being included in the medical record, and another resident's weight was recorded without the time, contrary to facility policy. Staff interviews revealed a lack of understanding regarding the importance of these records, highlighting deficiencies in documentation practices.
The facility failed to maintain proper concentration levels of sanitizer solution during the dishwasher's wash cycle, as observed on 05/07/2024. The Dietary Aide did not log the testing results, and the Dietary Manager relied solely on staff logs without performing random strip tests. The Administrator was unaware of the malfunction until informed by the surveyor.
A resident with a history of hip fracture and complex medical conditions fell twice from bed due to the facility's failure to update the care plan. The resident required two-person assistance during bed baths, but this was not documented or communicated to staff, leading to falls during unattended moments. The care plan was not revised after the first fall, resulting in a second fall under similar circumstances.
A resident with complex medical conditions and a history of falls was not provided adequate supervision during bed baths, resulting in two falls from the bed. Despite requiring substantial assistance, the facility failed to update the care plan to reflect the need for a two-person assist, leading to repeated incidents and hospitalizations.
Inaccurate MDS Assessment of Resident Behaviors
Penalty
Summary
The facility failed to ensure that assessments accurately reflected a resident's behavioral status, as evidenced by discrepancies between the resident's care plan, staff interviews, and the Minimum Data Set (MDS) documentation. The resident in question had a history of severe cognitive impairment, fluctuating behaviors, and multiple diagnoses including COPD, muscle weakness, depression, and a history of elopement and resistance to care. Despite these documented behaviors and staff observations of combative and resistant actions, the resident's Quarterly and Discharge MDS assessments indicated that no behavioral symptoms, rejection of care, or wandering were exhibited. Record reviews showed that the resident's care plan included specific notes about wandering, elopement risk, disorientation, frequent refusal of ADL care, yelling at other residents, and removing medical devices. Multiple staff interviews corroborated that the resident was confused, attempted to elope, was resistant to care, and displayed both physical and verbal behavioral symptoms. Staff described the resident as combative, not friendly, and prone to rejecting care several times a week. However, these behaviors were not reflected in the MDS assessments, which were marked as not exhibited for all behavioral symptoms. The MDS nurse, who was new and did not complete the resident's assessments, stated that the MDS is compiled using information from the interdisciplinary team, interviews, and observations. The DON confirmed that the MDS assessments for the resident were inaccurate and did not acknowledge the resident's physical, verbal, and other behavioral symptoms. Facility policy requires comprehensive and accurate assessments to inform care planning, but this was not followed in the resident's case, resulting in inaccurate documentation of the resident's needs and behaviors.
Failure to Administer IV Vancomycin at Ordered Rate and Without Proper Labeling
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to administer intravenous (IV) Vancomycin to a resident according to the physician's order and pharmacy instructions. The medication was ordered to be infused at a rate of 150 ml/hr, but the RN administered it at 250 ml/hr. The RN was aware of the correct rate but intentionally set the infusion at a higher rate due to the resident's combative behavior and the unavailability of an IV pump. The RN did not notify nursing management of this deviation from the order and was not fully aware of the specific risks associated with rapid Vancomycin infusion. The resident involved had multiple medical conditions, including COPD, muscle weakness, depression, difficulty walking, a right great toe amputation, a lower left leg open wound, and a peritoneal abscess. The resident also had severely impaired cognition, was disoriented, and exhibited behaviors such as wandering and resistance to care. At the time of the incident, the resident was receiving Vancomycin for an infection, and the medication was observed being administered at the incorrect rate. The IV bag in use did not have a proper pharmacy label with the resident's name, dose, and administration instructions, as required by facility policy. Interviews with facility staff confirmed that the medication should have been administered using a pump at the prescribed rate, and that all IV medications must have a pharmacy label with complete information. The nurse administering the medication did not follow these protocols, and the deviation from the ordered administration rate was considered a significant medication error by the medical director and pharmacy. The facility's policies require medications to be administered as prescribed, with verification of the label and adherence to the seven rights of medication administration.
Failure to Ensure Nurse Competency in IV Medication Administration
Penalty
Summary
A nurse (RN) administered intravenous (IV) Vancomycin to a resident without demonstrating competency in IV medication administration or the use of dial-a-flow tubing. The nurse intentionally set the infusion rate at 250 ml/hr, which was faster than the physician-ordered rate of 150 ml/hr, and did so without notifying nursing management, despite being instructed by the Assistant Director of Nursing (ADON) to wait for a medication pump from the pharmacy. The nurse was not aware of specific infusion reactions associated with Vancomycin, such as Red Man Syndrome, and had not received training on significant medication errors, IV medication administration, or the use of dial-a-flow tubing. No skills assessment had been completed for the nurse regarding IV medication administration prior to this incident. The resident involved had multiple complex medical conditions, including COPD, muscle weakness, depression, difficulty walking, a right great toe amputation, a lower left leg open wound, and a peritoneal abscess. The resident also had severely impaired cognition and was described as confused, combative, and not interviewable at the time of the incident. During the administration of Vancomycin, the IV bag lacked a pharmacy label with the resident's name, dose, and instructions for use, and the nurse stated the label must have fallen off. The nurse did not assess the resident for adverse reactions after the medication was administered at the incorrect rate and moved the resident to the dining room without completing any observations. Facility policy required that nurses demonstrate competency in medication administration, including IV medications, and that all medications be administered as prescribed, with proper labeling and verification. However, the facility did not have documentation of the nurse's competency in IV medication administration or the use of dial-a-flow tubing. The Director of Nursing (DON) confirmed that there was no system in place to double-check IV administration and that the facility relied on the competency of the nurse. The nurse's skills checklist did not include IV medication administration or dial-a-flow tubing competencies, and the nurse had not received any specific training on these procedures.
Significant Medication Error: IV Vancomycin Administered at Incorrect Rate
Penalty
Summary
A significant medication error occurred when a registered nurse (RN) intentionally administered an intravenous antibiotic, Vancomycin, to a resident at a rate of 250 ml/hr instead of the ordered 150 ml/hr. The pharmacy label clearly indicated the correct rate, but the RN did not follow the order and did not use a medication pump as required. The nurse was aware of the correct rate but chose to administer the medication more rapidly due to the resident's combative behavior and the unavailability of a pump. The nurse did not notify nursing management of the deviation from the order and did not perform an immediate assessment of the resident after the error. The resident involved had multiple medical conditions, including COPD, muscle weakness, depression, a history of amputation, and an open wound, and was noted to have severely impaired cognition. At the time of the incident, the resident was confused, combative, and not interviewable. The Vancomycin was administered using dial-a-flow tubing, which the nurse had not previously used and for which she had not received training. The IV bag was missing a pharmacy label at the time of administration, and the nurse later retrieved a new label confirming the correct infusion rate. The nurse admitted to not having received training on significant medication errors, IV medication administration, or the use of dial-a-flow tubing prior to this incident. Facility policy required medications to be administered as prescribed, with staff verifying the label and following the seven rights of medication administration. The nurse did not follow these procedures, and the error was not immediately reported or managed according to policy. Interviews with facility leadership and pharmacy staff confirmed that the medication was not administered as ordered and that the nurse had not been properly oriented or assessed for competency in IV medication administration.
Failure to Properly Label and Store IV Medication
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to ensure that an intravenous (IV) Vancomycin medication administered to a resident was properly labeled in accordance with professional standards and facility policy. During observation, the IV bag in use for the resident did not have a pharmacy label containing the resident's name, medication information, directions for use, administration flow rate, prescriber name, or date of order. The RN acknowledged that the label must have fallen off after hanging the medication and confirmed that all medications are required to have a pharmacy label with the necessary information. The Director of Nursing (DON) also confirmed that all IV medications should be labeled with pharmacy and resident information, as well as directions for use. The resident involved had multiple medical conditions, including COPD, muscle weakness, depression, difficulty walking, a right great toe amputation, a lower left leg open wound, and a peritoneal abscess. The resident also had severely impaired cognition and a history of wandering and removing medical devices. The facility's policy required infusion therapy products to be labeled with specific information to ensure safe administration, but this was not followed in this instance, as observed and confirmed by staff interviews and record review.
Failure to Timely Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily direct care staffing information was posted and readily accessible for review as required. On the morning of 11/12/25, observations revealed that the Direct Care Daily Staffing Numbers displayed at both the front entrance and by the DON's office were dated for the previous day, 11/11/25, rather than being updated for the current day. The postings included the facility name, census, scheduled hours, and staffing totals for direct care staff, but were not current as required. The facility operated with 12-hour shifts for RNs, LVNs, and some CNAs, and other staff had varying shift times. The outdated posting was later observed being removed by the Staffing Coordinator. Interviews with the Administrator and the Staffing Coordinator confirmed that the Staffing Coordinator was responsible for updating the daily direct care posting within two hours of the start of the first shift, which begins at 6:00 AM. The Staffing Coordinator stated that her shift typically started at 8:15 AM and that she was expected to update the posting within two hours of her arrival. She reported that on the day in question, her update was delayed because she was assisting residents on the floor and had not received training regarding the regulations for the timing of the posting. Both the Administrator and the Staffing Coordinator acknowledged that failure to update the posting in a timely manner could result in confusion for residents and visitors regarding the facility census and available staffing.
Failure to Include Respiratory Interventions in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple respiratory diagnoses, including acute respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea (OSA). Despite the resident having active physician orders for continuous oxygen therapy and nightly use of a BiPAP (non-invasive ventilator), these interventions were not documented in the resident's care plan. The care plan only addressed risks related to falls and pain management, omitting the resident's respiratory needs and the required interventions for oxygen and BiPAP use. Record reviews showed that the resident had a history of respiratory failure, pneumonia, morbid obesity, and COPD, and was receiving both oxygen and non-invasive ventilation as ordered by her physician. The medication administration records confirmed that these treatments were being provided. However, the care plan did not reflect these critical interventions, nor did it include measurable objectives or timeframes related to the resident's respiratory care, as required by facility policy and regulatory standards. Interviews with facility staff revealed that the nurse responsible for care plans was unaware of the need to include the resident's respiratory diagnoses and interventions until reviewing the orders. The nurse acknowledged that the care plan should have been updated upon admission to include these needs. The Director of Nursing also confirmed that the resident's respiratory needs should have been documented in the care plan to inform the interdisciplinary team and ensure continuity of care.
Unsecured Medication Found at Bedside Without Self-Administration Order
Penalty
Summary
Surveyors identified a deficiency in the facility's medication storage practices when a Fluticasone inhaler prescribed for a female resident with a history of acute respiratory failure, COPD, pneumonia, heart failure, and morbid obesity was found unsecured on the resident's nightstand. The resident was alert, oriented, and receiving oxygen therapy at the time of observation. There was no physician's order for self-administration of the inhaler, nor was there a documented assessment for the resident's ability to self-administer medications. Multiple staff interviews confirmed that medications should not be left in resident rooms unless there is a specific physician order for self-administration, which was not present in this case. Staff members, including medication aides and nurses, were unable to explain why the inhaler was left at the bedside and acknowledged that only authorized personnel should administer medications. The Director of Nursing also confirmed that medications should not be left at the bedside without proper orders and assessment. A review of the facility's medication storage policy indicated that all drugs and biologicals must be stored in locked compartments and that nursing staff are responsible for maintaining safe and secure medication storage areas. The failure to secure the inhaler and ensure only authorized access to medications was found to be inconsistent with both facility policy and regulatory requirements.
Failure to Properly Store and Seal Food Items in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an initial kitchen observation, it was found that bulk foods were not stored in a manner to prevent contamination. Specifically, a plastic bag of dry spiral noodles in the dry storage area was not sealed and was exposed to air. In the freezer, several cardboard boxes containing frozen hamburger patties, breakfast patties, and biscuits were also not sealed and were exposed to air. An interview with the Dietary Manager confirmed that all food should be closed when stored in the dry food area, refrigerator, or freezer to maintain freshness and prevent contamination. The Dietary Manager acknowledged that it was the kitchen staff's responsibility to seal and label food items, but was unaware of who failed to do so. A review of the facility's policy on refrigerator and freezer maintenance indicated that all food should be appropriately dated and sealed to ensure proper rotation and prevent contamination.
Failure to Maintain Clean and Sanitary Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required the use of non-invasive ventilators (BiPAP) and oxygen therapy. Observations revealed that the BiPAP masks for both residents were not stored in plastic bags when not in use, as required by facility policy and infection control standards. Instead, the masks were left exposed on nightstands or draped over equipment, with the plastic storage bags either underneath the mask or hanging on a wall hook nearby. Multiple staff members, including medication aides and licensed vocational nurses, confirmed during interviews that the masks should have been stored in plastic bags to prevent contamination, but were unable to explain why this was not done. One resident had a history of acute respiratory failure, COPD, pneumonia, heart failure, and obstructive sleep apnea, and was receiving nightly BiPAP therapy with oxygen as ordered by her physician. Her care plan did not address the need for BiPAP or oxygen therapy. The other resident, with diagnoses including hemiplegia following a stroke, diabetes, morbid obesity, and obstructive sleep apnea, also received nightly BiPAP and continuous oxygen therapy. Her care plan included interventions for oxygen therapy and BiPAP use, noting frequent refusals of the BiPAP, but did not address the improper storage of respiratory equipment. Interviews with the Director of Nursing and staff confirmed the expectation that BiPAP masks be stored in plastic bags when not in use for infection control purposes. The facility's policies and in-service training materials also specified that oxygen therapy equipment must be kept clean and sanitary, with masks and cannulas covered when not in use. Despite these policies and training, the required infection control practices were not consistently followed, as evidenced by the improper storage of respiratory equipment for both residents.
Failure to Administer Medications as Ordered by Physician
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for a resident. Specifically, a medication aide (MA-Q) administered a multivitamin with minerals to a resident instead of the ordered multivitamin, as documented in the resident's medication administration record. The resident, an elderly female with multiple diagnoses including osteoporosis, diabetes, hypertension, and dementia, had a physician's order for a multivitamin without minerals. Observations confirmed that the incorrect medication was prepared and administered, and the medication aide later confirmed giving the multivitamin with minerals rather than the prescribed multivitamin. Interviews with staff, including another medication aide, an LVN, and the DON, revealed awareness of the importance of administering the correct medication and the differences between a multivitamin and a multivitamin with minerals. The facility's policy required verification of medication orders and checking medication labels against the electronic medication administration record, but these procedures were not followed in this instance, resulting in the administration of the wrong medication to the resident.
Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during incontinent care for one resident. During observation, two CNAs performed perineal care without adhering to established hand hygiene and glove-changing protocols. Specifically, after cleaning the resident's groin and peri-anal areas, one CNA did not remove soiled gloves or perform hand hygiene before handling clean items such as a new brief and barrier cream. The same CNA only changed one glove and continued to use the other, which had been exposed to contaminated areas, to touch clean items and bedding. Both CNAs failed to perform hand hygiene before leaving the resident's room, instead using hand sanitizer only after exiting or not at all in the immediate area. The resident involved was a female with multiple diagnoses, including acute respiratory failure, pneumonia, heart failure, cellulitis, and morbid obesity. She was always incontinent of urine and frequently incontinent of bowel, requiring staff assistance for toileting and hygiene. The care plan indicated a need for substantial assistance with personal hygiene and emphasized maintaining the highest level of function in daily activities. Interviews with staff revealed inconsistent understanding and application of infection control protocols. One CNA believed it was acceptable to use a glove that appeared clean to handle clean items, while another CNA acknowledged the risk of cross-contamination and the importance of changing gloves and performing hand hygiene. The DON confirmed that staff were expected to follow proper procedures, including changing gloves and sanitizing hands at appropriate times, and that staff had received in-service training on these protocols. Facility policies reviewed supported the need for strict hand hygiene and glove use during resident care.
Failure to Document Hearing Aid Use in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with moderate cognitive impairment and hearing impairment. The resident's care plan did not document the use of hearing aids as an assistive device, which was necessary for her to understand verbal communication. This omission was noted despite the resident's quarterly MDS assessment indicating the use of hearing aids and the resident's ability to usually understand verbal content with the aid of these devices. The lack of documentation in the care plan and Kardex led to confusion among staff members, as they relied on these documents to determine the resident's needs. Interviews with CNAs and other staff revealed that without proper documentation, staff who were not familiar with the resident might not provide the necessary assistance with hearing aids, potentially leading to communication difficulties and emotional harm for the resident. The facility's policy on care planning and hearing aid care was not followed, as the care plan did not reflect the resident's need for hearing aids. The resident's family expressed concerns about the facility's assistance with hearing aids, noting instances where the resident was without them, including a period when they were lost. The facility had to reimburse the family for the lost hearing aids, indicating a lapse in the continuity of care. Interviews with the DON and ADM confirmed that the expectation was for assistive devices to be documented in the care plan, which was not done in this case, increasing the risk of missed care for the resident.
Deficient Record-Keeping Practices in Resident Care
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, which could lead to errors in care and treatment. For Resident #2, the facility did not retain the hospital Nurse Report, which contained vital information about the resident's condition upon transfer from the hospital. This report was shredded instead of being included in the resident's permanent medical record. Interviews with staff revealed a lack of understanding regarding the importance of the Nurse Report as part of the resident's medical record, with some staff considering it merely a reference point rather than a necessary document to retain. For Resident #3, the facility did not accurately document the time the resident was weighed, which is a requirement according to the facility's policy. The resident's weight was recorded on paper without the time of weighing, which is crucial for monitoring the resident's nutritional status and ensuring accurate clinical outcomes. The Director of Nursing (DON) acknowledged that the facility policy required the time of weighing to be documented, but this was not being followed. Interviews with various staff members, including the DON, Licensed Vocational Nurses (LVNs), and the Medical Records Personnel (MRP), highlighted inconsistencies in the understanding and implementation of record-keeping policies. The Administrator (ADM) admitted that the Nurse Report should be part of the resident's medical record and expressed surprise that it was being shredded. The failure to maintain accurate and complete medical records for these residents reflects a deficiency in the facility's documentation practices, which could potentially impact the quality of care provided to residents.
Failure to Maintain Proper Sanitizer Levels in Dishwasher
Penalty
Summary
The facility failed to serve food in accordance with professional standards for food safety by not maintaining the proper concentration level of sanitizer solution during the dishwasher's wash cycle. This was observed on 05/07/2024 at 9:05am when the facility's only low-temp dishwasher did not dispense the correct amount of sanitizer solution. Dietary Aide A performed a strip test after a load of dishes had been washed, and the test did not change color after six attempts, indicating lower than minimum PPM levels of sanitizer solution. The issue was not logged prior to the observation, and the Dietary Manager confirmed that she relied solely on staff logs and did not perform random strip tests herself. The facility's policy required kitchen staff to log concentration levels of sanitizing solution each shift during wash cycles, but this was not done that morning. The Administrator was unaware of the dishwasher's malfunction until informed by the surveyor on 05/07/2024. He confirmed that the facility's policy required logging concentration levels with testing strips each shift. The facility's policy, revised in March 2010, stated that a supervisor would check the dishwasher machine for proper concentrations of sanitizer solution after filling the machine and once a week thereafter. The failure to maintain proper sanitizer levels could affect all residents by placing them at risk for food-borne illness due to cross-contamination and diseases.
Failure to Update Care Plan Leads to Resident Falls
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident, leading to two falls from bed. The resident, who had a history of a hip fracture, diabetes, muscle weakness, and other complex medical conditions, fell out of bed twice while receiving bed baths. The first fall resulted in a hip fracture, and the second fall occurred after the resident returned from the hospital. Despite the resident's complex medical history and risk factors, the care plan was not updated to include necessary interventions to prevent falls. The first fall occurred when a CNA was giving the resident a bed bath, and the resident fell off the bed due to inadequate support and assistance. The CNA involved in the incident was in-serviced individually, but the care plan was not updated to reflect the need for additional assistance during bed baths. The second fall happened under similar circumstances, with another CNA leaving the resident unattended on the side of the bed during a bed bath. This incident highlighted the lack of communication and proper documentation regarding the resident's care needs. Interviews with staff revealed that the care plan and Kardex were not updated to reflect the resident's need for two-person assistance during bed baths and other activities. The facility's policy required care plans to be updated following significant changes in a resident's condition, but this was not done in a timely manner. The failure to update the care plan and communicate the necessary interventions to staff placed the resident at risk for further harm.
Inadequate Supervision During Bed Baths Leads to Resident Falls
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident during bed baths, resulting in two separate incidents where the resident fell off the bed. The resident, who had a history of a hip fracture, diabetes, muscle weakness, and other complex medical conditions, was cognitively intact but required substantial assistance with bed mobility. Despite these needs, the facility did not implement sufficient fall prevention measures or update the care plan to reflect the resident's need for a two-person assist during bed baths. On two occasions, the resident fell off the bed while receiving a bed bath, leading to hospitalizations. The first incident occurred when a CNA was providing a bed bath and the resident rolled off the bed, resulting in a fractured hip. The second incident happened when another CNA left the resident unattended on her side to change the bath water, during which the resident fell again. Interviews revealed that the CNAs were not adequately informed or trained on the resident's need for a two-person assist, and the care plan was not updated to reflect this requirement after the first fall. The facility's inaction in updating the care plan and ensuring all staff were aware of the resident's needs contributed to the repeated falls. The lack of communication and training among staff regarding the resident's fall risk and necessary precautions were significant factors in the deficiency. The facility's failure to implement comprehensive fall prevention strategies and update care plans in a timely manner placed the resident at risk for further accidents and injuries.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Houston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Paradigm At Woodwind Lakes | 1.8 mi | — | 22 | 1 |
| Fallbrook Rehabilitation And Care Center | 2.8 mi | ★★★★★ | 17 | 4 |
| Park Manor Of Cyfair | 2.8 mi | ★★★★★ | 1 | 0 |
| Misty Willow Healthcare And Rehabilitation Center | 4.3 mi | ★★★★★ | 16 | 5 |
| North Houston Transitional Care | 4.6 mi | ★★★★★ | 1 | 0 |
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