Legacy Place Cottages.

“During a fire drill at 11:33 p.m., a resident in a room did not evacuate to a designated meeting place away from the building or within the fire-safe areas.”

“Poisonous materials including bleach, air freshener, and zinc oxide were found unlocked and unattended in the laundry room and storage room of the memory care unit, accessible to residents. Additionally, a hair salon door in the secure dementia building was unlocked with harmful barbicide liquid and clippercide aerosol found inside.”

“The lid to the shared memory care common area bathroom trash can was missing the flap to cover the trash. Additionally, the trash can in the shared bathroom of room 203 did not have a lid, failing to prevent penetration of insects and rodents.”

“The water temperature in a bathroom sink located in a resident room exceeded 120°F as required by regulation.”

“Two clear bottles of orange juice in the memory care refrigerator were not labeled with contents or storage dates. Additionally, an unlabeled and undated flat of eggs was found in the memory care refrigerator. This is a repeated violation.”

“There was no thermometer in the memory care refrigerator as required to monitor food storage temperature.”

“The facility exceeded the maximum safe evacuation time specified by the fire safety expert of 6 minutes and 45 seconds during multiple fire drills, with evacuation times ranging from 2 minutes 56 seconds to 7 minutes and 14 seconds across both personal care and memory care buildings.”

“A partially used bag of frozen corn was found in the freezer without a date label indicating when it was opened. Food storage regulations require that leftover food be labeled and dated.”

“A discontinued medication ointment was found in the medication cart for Resident #1. Only current prescription, OTC, sample and CAM medications for individuals may be kept in the home.”

“Resident #2's medication label did not accurately reflect current prescriber orders. The medication label indicated different dosage and application instructions than the resident's actual PRN order, and an additional current PRN order for the resident was not properly labeled.”

“On 10/2/24 at 9pm, a medication administered to Resident #2 was not recorded with initials on the Medication Administration Record to indicate administration as scheduled.”

“Resident #2 has an order for a nasal gel medication to apply to left nare at bedtime, but the home was administering a nasal saline spray instead of following the prescriber's specific order.”

“A resident reported unauthorized charges on their credit card. Police investigation determined that a staffing agency employee (not a direct staff member) used the resident's credit card for gas without authorization and returned it without the resident's knowledge.”

“An undated white frozen beverage in an Arby's cup was found in the freezer of the home's kitchen. Food served and returned from an individual's plate may not be served again, and leftover food must be labeled and dated.”

“The freezer located in the kitchen of the Personal Care Home did not contain a thermometer. Food requiring refrigeration must be stored at or below 40°F, frozen food at or below 0°F, and thermometers are required in refrigerators and freezers.”

“On 9-6-23 menus were posted through 9-9-23 only. Menus must be prepared for one week in advance and posted one week in advance in a conspicuous public place.”

“Resident 1 had a prescription for Guggul Extract 500 MG supplement that was discontinued on 8-24-23. On 9-6-23, the discontinued prescription medication was still available in the medication cart. Only current prescription, OTC, sample and CAM for individuals may be kept in the home.”

“The Resident Assessment Support Plan for Resident 2 was not updated to include the significant change of multiple rib fractures. Support plans must be revised within 30 days upon completion of annual assessment or upon changes in resident's needs.”