Legacy Manor.

“Based on record review and interview, the manager failed to ensure that a medication administered to a resident was documented in compliance with a medication order for one of two sampled residents who received medication administration services. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication.   Findings Include:   1. A review of R1’s medical record revealed a medication order dated April 11, 2025, for Citalopram (Celexa) 10 mg one tablet once daily. R1’s service plan reflected that R1 received medication administration services.   2. The compliance officer observed a medication bottle for Citalopram (Celexa), which reflected it was dispensed on April 28, 2025.   3. A review of R1’s medical record revealed a medication administration record (MAR) dated April 2025 reflecting R1 was administered Citalopram (Celexa) from April 23, 2025, to April 27, 2025, at 8 am, despite the medication being dispensed on April 28, 2025. There was no evidence there was a previous Citalopram order.   4. In an interview, E1 reviewed R1’s Citalopram medication bottle, 2025 April MAR, and medication order, and acknowledged R1's Citalopram medication was not administered before R1's Citalopram was dispensed from the pharmacy. E1 acknowledged there was not a previous order of Citalopram.”

“Based on observation and interview, the manager failed to ensure the premises and equipment were free from a condition or situation that may cause a resident or other individual to suffer physical injury. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed an uncovered hole roughly 4 inches wide inside the facility's shower. The uncovered hole presented a tripping hazard and could cause a resident to slip, fall, or cut themselves while in the shower. 2. In an interview, E1 acknowledged the uncovered hole inside the facility's shower.”

“Based on observation, documentation review, and interview, the manager failed to ensure a pet was vaccinated against rabies. Findings include: 1. The surveyor observed O1 to be the only pet in the facility.  2. A review of facility documentation revealed a rabies vaccination for O1, which expired on March 26, 2025. 3. In an interview, E1 acknowledged there was no documentation to reflect that O1 was currently vaccinated against rabies.”