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.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment on two of four floors (Third Floor and Fourth Floor).

A review of the facility’s resident rights revealed that each resident has the right to a safe, clean, comfortable, and homelike environment including, but not limited to, receiving treatment and support for daily living safely.

During an observation tour on the Fourth Floor on 2/20/2024 at 2:00 pm, double occupancy rooms and quad occupancy rooms were observed. The quad shared rooms were set up with four beds lined up in a row with curtain dividers in between them on one side of the room. Clothing closets were on the opposite side of the room near the door entrance for all four residents; these closets are not located near the resident’s living space. These rooms appear to be set up institution-like. room [ROOM NUMBER]D was observed to have a broken and peeling bed stand. The divider privacy curtains were broken. room [ROOM NUMBER]D was observed to have a cloth covered chair that was badly stained at the resident’s bedside. room [ROOM NUMBER]D was observed to have a bedside stand with peeling and chipped paint. room [ROOM NUMBER], which was a quad room, revealed broken privacy curtains and missing wall moldings.

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Based on observations, interviews, and record review, the facility failed to ensure eight of 30 sampled residents (R) (R16, R17, R19, R12, R1, R18, R30 and R22) were free from abuse.

On 2/28/2024, a determination was made that a situation in which the facility’s noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents.

The facility’s Administrator and Director of Nursing were informed of the Immediate Jeopardy (IJ) on 2/28/2024 at 3:05 pm.

Ensure each resident receives an accurate assessment.

Based on observations, interviews, and record review, the facility failed to ensure the accuracy of the comprehensive assessment addressed the wandering behaviors for one of 30 sampled residents (R) (R1). R1’s wandering led to physical altercations with multiple residents, including a physical altercation on 1/25/2024 when R1 wandered into R12’s room and R12 pushed R1, causing R1 to sustain a fracture of the left elbow.

On 2/28/2024, a determination was made that a situation in which the facility’s noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents.

The facility’s Administrator and Director of Nursing were informed of the Immediate Jeopardy (IJ) on 2/28/2024 at 3:05 pm.

Provide care and assistance to perform activities of daily living for any resident who is unable.

Based on observations, interviews, record review, the facility failed to provide Activities of Daily Living (ADL) care for eight of 30 sampled residents (R) (R4, R21, R29, R23, R25, R26, R27, and R28) related to toileting and nail care.

Ensure each resident must receive and the facility must provide necessary behavioral health care and services

Based on observation, staff interview, and record review, the facility failed to monitor and document behaviors for one resident (R1) who was involved in multiple resident-to-resident physical altercations due to wandering on the unit. The sample size was 30 residents.

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Based on observation, interview, record review, and policy review, the facility failed to ensure one resident (R8) of 30 sampled residents received adequate assistance and support from social services with receiving urgent dental services.

Provide routine and 24-hour emergency dental care for each resident

Based on observation, interview, record review, and policy review, the facility failed to ensure one resident (R8) of 30 sampled residents received dental services timely, after multiple requests and complaints of mouth pain.

Administer the facility in a manner that enables it to use its resources effectively and efficiently

Based on record review, interviews, and review of the Administrator’s Job Description, Administration failed to provide protective oversight of the facility environment including adequate supervision for wandering residents and failed to protect residents on the secured memory unit from an abuse free environment. This failure had the likelihood of affecting all residents residing on the secured memory unit. In addition, the facility failed to ensure that the call light communication system was functioning to alert staff that residents required assistance on one of four floors (Fourth Floor) in the facility.

On 2/28/2024, a determination was made that a situation in which the facility’s noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents.

Make sure that a working call system is available in each resident’s bathroom and bathing area.

Based on observations, interviews, and record reviews, the facility failed to ensure that the call light communication system was functioning to alert staff that residents required assistance on one of four floors (Fourth Floor) in the facility.