Legacy Estate Long Term Care

In the surveyor’s words

From the most serious findings on record at Legacy Estate Long Term Care, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jul 1, 2025

  Based on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed.The facility failed to ensure foods were labeled properly in the kitchen. These failures could place residents that eat out of the kitchen at risk for food borne illnesses.The findings included:During an observation and interview on 06.29.2025 between 01:25 PM and 4:15 PM AM of the kitchen revealed:Refrigerator #1 1. Refrigerator contained one pitcher of lemonade (approximately 100 mL) with a use by date 06.28.25 Dry storage1. 1 large clear plastic bag with what appeared to be coconut flakes, sealed with no label or use by date.2. […]

• No harm, potential for more than minimal, widespreadF851Jul 1, 2025

  Based on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS , for 1 of 1 (FY Quarter 2 2025) reviewed for Staffing Data Report.The facility failed to submit staffing information to CMS for FY Quarter 2 2025 (January 1- March 31).The facility's failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and… […]

• No harm, potential for more than minimal, patternF755Aug 25, 2026

  Based on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate administering of all drugs and biologicals to meet the needs of the residents for 1 of 2 medication rooms and 1 (North Hall Med Cart) of 3 medication carts reviewed for drugs and biologicals. 1. The facility failed to ensure six jars of Fleet Rectal Glycerin suppositories (used rectally for constipation) were removed from the refrigerator in the North Hall medication room when they had expired on 05/01/2025.2. […]

• No harm, potential for more than minimal, patternF812Aug 25, 2026

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food safety. The facility failed to ensure foods were labeled properly in the kitchen.The facility failed to ensure open packages were sealed and dated. These failures could place residents that eat out of the kitchen at risk of food borne illnesses.Findings included: During an observation on 08/23/2026 at 10:00am revealed an open bag waffle shaped fries not sealed, not labeled or dated in the freezer in the kitchen. […]

• No harm, potential for more than minimal, isolatedF695Aug 25, 2026

  Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 of 6 (Resident #87) residents observed for oxygen management. The facility failed to post a no smoking oxygen in use sign indicating Resident #87 received oxygen on 08/23/2026, 08/24/2026, and 08/25/2026.This failure could place residents at risk of receiving incorrect or inadequate oxygen support; decline in health; and at risk of fire hazards.Findings Included:Record review of Resident #87's electronic face sheet dated 08/25/2026 reflected an [AGE] year-old female who admitted on [DATE] and re-admitted on [DATE] with diagnosis of COPD (chronic respiratory disease that obstructs the… […]