Legacy Heights Nursing and Rehab, LLC

In the surveyor’s words

From the most serious findings on record at Legacy Heights Nursing and Rehab, LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF609Sep 29, 2022

  Based on observations, interviews, and record review, the facility failed to ensure Resident #1 and Resident #4 were free from verbal/mental abuse, as evidenced by the facility's failure to ensure staff reported allegations of verbal/mental abuse in a timely manner, which resulted in failure to ensure an investigation was promptly initiated and protective measures were immediately implemented to prevent further potential abuse for 2 (Resident #1 and Resident #4) of 4 (Residents #1, #2, #3, and #4) sampled residents. […]

• Immediate jeopardy, isolatedF610Sep 29, 2022

  Based on observations, interviews, and record review, the facility failed to ensure Resident #1 and Resident #4 were free from verbal/mental abuse, as evidenced by the facility's failure to ensure staff reported allegations of verbal/mental abuse in a timely manner, which resulted in failure to ensure an investigation was promptly initiated and protective measures were immediately implemented to prevent further potential abuse for 2 (Resident #1 and Resident #4) of 4 (Residents #1, #2, #3, and #4) sampled residents. […]

• No harm, potential for more than minimal, widespreadF812Apr 18, 2024

  Based on observation and interview, the facility failed to ensure food items stored in the refrigerator were covered, sealed, and dated, kitchen walls, door frames and baseboards were free of rotten wood, chipped walls were replaced, dietary staff washed their hands when contaminated to decrease the potential for food borne illness for residents who received food from 1 of 1 kitchen, 2 of 2 ice machines were maintained in a clean and sanitary condition and dietary staff washed their hands and changed their gloves before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 82 residents who received meals from the kitchen (total census: 82). The findings are: 1. […]

• No harm, potential for more than minimal, widespreadF812Jan 20, 2023

  Based on observation, interview, and record review, the facility failed to ensure foods stored in the kitchen freezer, refrigerators, and dry storage area were labeled and dated when received and/or opened; foods in resident refrigerators on the halls were labeled and dated; cookware was cleaned and sanitized between uses; 1 of 2 ice machines was maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages, and to prevent potential food borne illness for residents who received meals from 1 of 1 Kitchen. These failed practices had the potential to affect 73 residents who received meal trays and beverages from the Kitchen as documented on a Diet list provided by the Administrator on 1/20/23. The findings are: 1. […]

• No harm, potential for more than minimal, patternF812Jul 31, 2025

  Based on facility policy review, record review, observations and interviews, it was determined that the facility failed to ensure ice machines were maintained in a clean condition to minimize the risk for food borne illness in one of two ice machines observed. Based on facility policy review, record review, observations and interviews, it was determined that the facility failed to ensure ice machines were maintained in a clean condition to minimize the risk for food borne illness in one of two ice machines observed. The findings include: During an observation on 07/31/2025 at 12:15 PM, Dietary Aide (DA) #1 used a white paper towel to wipe the interior of the ice machine. An unknown tan and gray substance transferred to the paper towel. […]