ATLANTA, GA- LEGACY TRANSITIONAL CARE & REHABILITATION

The Department of Health & Human Services conducted an inspection of the facility. The following highlighted decencies listed below were found in a public survey. 

Honor the resident’s right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45108

Based on observations, and resident and staff interviews, the facility failed to maintain a safe, clean, comfortable, homelike environment in twelve of 84 Residents rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) were found to have unclean conditions, broken tile, and unsafe surfaces. In addition, the third floor west and east shower room floors were unclean, and a mechanical door was left open and unlocked.

The findings include:

The facility did not provide a housekeeping policy for the survey team.

Observation 10/10/2023 at 10:35 am revealed the third-floor mechanical room door was open, and no staff was present in the room. A sign on the door read, Door to Remain Locked at All Times.

Interview on 10/10/2023 at 10:37 am with Licensed Practical Nurse (LPN) LL revealed the mechanical room door should always be locked, especially since the third floor was a secured memory care unit.

Observation on 10/10/2023 at 10:40 am revealed the Maintenance Assistant (MA) MM said contractors were in the facility putting in a new call light system and must have left the mechanical room door open. MA MM stated it was dangerous to keep the mechanical room door open; that residents could be harmed if they wandered into the room.

Observation 10/10/2023 at 10:45 am in room [ROOM NUMBER] revealed dirt and dust on the baseboards of the room. The privacy curtain between beds A and B had small areas of a brown stain on the bottom portion.

Observation 10/10/2023 at 11:05 am in room [ROOM NUMBER] revealed dust and debris on the baseboards of the room and in the far corner of the room. The privacy curtain for bed B was partially detached from the ceiling frame. At the head of bed D there was an area of plaster repaired directly under the light which had not been sanded or painted.

Observation 10/10/2023 at 11:10 am in room [ROOM NUMBER] revealed a large area of scraped paint with exposed drywall directly behind bed B. The privacy curtain for bed A had three small areas of a brown stain. The bed B privacy curtain had three large areas of brown stains and one small area of brown stain. The bed C privacy curtain had four areas of brown stain. The bed D privacy curtain had eight small areas of brown stains and one large area of brown stain.

Observation 10/10/2023 at 11:14 am in room [ROOM NUMBER] revealed the privacy curtain bed B had several brown stains. The privacy curtain for bed C had numerous brown stains. The privacy curtain for bed D was partially detached from the ceiling frame and had several brown stains. There were large areas of dark and light brown stains on the floor tile directly under the heating/air conditioning unit of room. In the far corner of the room there was an area of tile that lifted away from the main flooring, and there was also dirt/debris in the corners of the room.
Observation 10/10/2023 at 11:20 am in room [ROOM NUMBER] revealed a portion of the baseboard was missing. Baseboards had built up dust and dirt. The walls throughout the room had areas of dirt.

Observation 10/10/2023 at 11:24 am in room [ROOM NUMBER] revealed bed A had a privacy curtain with two small brown stains and one large brown stain.

Observation 10/10/2023 at 11:27 am in room [ROOM NUMBER] revealed an area of floor transition strip missing from the floor entrance of room causing an uneven surface and a safety issue. The privacy curtain between bed A and B had four small areas of brown stains.

Observation 10/10/2023 at 11:35 am in room [ROOM NUMBER] revealed the door and door frame to the room had scuffed areas and missing paint and there was an area of floor tile missing in the room.

Observation 10/10/2023 at 11:50 am revealed the third-floor west shower room had a mop bucket with brown water with a mop in the bucket sitting in the middle of the floor upon entrance into the shower room. The flooring throughout the shower room had areas of rust-colored stains, and the baseboards had areas of peeling paint. The shower had a large area of brown colored stain on the wall. There were areas of a brown colored substance in the corners of the toilet area of the shower room.

Observation 10/10/2023 at 12:05 pm revealed the third-floor east shower room flooring was observed to have areas of brown stains throughout the shower room. The walls of the shower room had areas of brown colored stains, and dirt and debris were noted in all corners of the shower room.

Observation 10/10/2023 at 1:00 pm of room [ROOM NUMBER] revealed the baseboards in the room had a film of dust and a brown substance in all corners of the room.

Observation 10/10/2023 at 1:39 pm of room [ROOM NUMBER]’s bathroom revealed accumulation of a black substance around the edges of the bathroom baseboards.

Observation and interview 10/10/202 at 3:18 pm of room [ROOM NUMBER] revealed the floors to be soiled with a buildup of particulate matter in the corners. Resident (R) (R 91) complained about the cleanliness of the environment.

Observation and interview 10/11/2023 at 1:15 pm revealed R62 in room [ROOM NUMBER]. When asked about the spills and splashes on the wall in room [ROOM NUMBER], which were at eye level adjacent to the resident, he stated housekeeping should clean better.

Interview 10/12/2023 at 9:10 am with Housekeeper B, revealed she had been employed for about three (3) months. She stated the residents’ rooms were cleaned daily, which consisted of sweeping, mopping, dusting, and emptying the trash. The housekeeper also stated no training was provided regarding deep cleaning of resident rooms.

Interview 10/11/2023 at 9:00 am with Housekeeping Supervisor (HS) NN, he stated that the housekeeping department had just transitioned from an outside contractor to in house housekeeping staff. He said there had not been a cleaning schedule developed for the housekeeping department since the outside contractor left on 9/30/2023.

Interview 10/11/2023 at 9:15 am with Housekeeping Manager (HM) MM revealed he started as the manager of the housekeeping department at 8:00 am that morning. He stated that the contract housekeeping company could not keep staff.

Interview 10/13/2023 at 8:30 am with the Director of Nursing (DON) revealed the Administrator had been on leave and would be returning to the facility that morning. The DON stated she and the Administrator had started working at the facility on 9/18/2023. She said their first Quality Assurance (QA) meeting was scheduled in two weeks, and they planned to develop housekeeping rounds as part of the QA program. The DON said the facility had a third-party contractor that provided housekeeping services for the facility, and that the contract was terminated on 10/1/23 due to unsatisfactory work performance. She said the facility was now using facility staff in the housekeeping department, and the new department head for the housekeeping department started on 10/11/2023.