Legacies Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Legacies Nursing and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Mar 18, 2026

  Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure the temperature for the dish machine was at the appropriate temperature of 120 degrees Fahrenheit during the wash cycle according to the manufacturer's guidelines to sanitize dishes appropriately on 03/01/26 through 3/17/26. This failure could place residents who eat from the kitchen at risk of foodborne illnesses.Findings included: During initial kitchen observation on 03/16/2026 at 9:05 am, Dietary Manager was observed running dishwasher and the temperature did not go above 110 during testing. The dietary manager said it had been like that. […]

• No harm, potential for more than minimal, patternF644Dec 20, 2023

  46273 46436 Based on interview and record review, the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change of condition for 4 of 6 Residents (Resident #49, Resident #56, Resident #67, and Resident #76) reviewed for PASSAR (Preadmission Screening and Resident Review Services) in that: 1. The facility failed to ensure Resident #49 had a PASSAR level II evaluation completed with a diagnosis of psychotic disorder (abnormal thinking and perceptions). 2. […]

• No harm, potential for more than minimal, patternF690Dec 20, 2023

  46436 Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 3 residents (Resident #1 and Resident # 24) reviewed for quality of care. The facility failed to ensure Residents #1 and 24's indwelling catheters (drains urine from your bladder into a bag outside your body) had a securement device to anchor their catheters. This failure could place residents at risk for urinary tract infections and catheter related injuries. Findings: 1. Record review of facility face sheet dated 12/21/2023 revealed Resident #1 was a [AGE] year-old female that admitted on [DATE] with diagnosis of chronic kidney disease and urinary tract infection (UTI). […]

• No harm, potential for more than minimal, patternF880Dec 20, 2023

  Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 8 staff (CNA G, CNA Q, CNA N) and for 2 of 5 residents reviewed for infection control (Resident #9 and Resident #45). 1. The facility failed to ensure MA P wore gloves when administering eye drops to Resident #45. 2. The facility failed to ensure the Treatment nurse used a clean gauze pad to dry a wound for Resident #9. 3. […]

• No harm, potential for more than minimal, patternF761Nov 2, 2022

  Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 2 of 2 medication carts (nurse cart for halls 100/200 and 300/400). The facility did not dispose of expired insulins for Resident #76 and glucose control solutions from the nurse medication carts for halls 100/200 and 300/400. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications, decreased quality of life, and hospitalization . […]