Legacy Nursing and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Dec 6, 2021

  Based on interview and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for one (Resident #1) reviewed for quality of care. The facility failed to ensure: LVN C obtained physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN C did not inform the DON or PCP when the Life Vest placed on Resident #1 by the Cardiologist's team while she was on duty. The RN/MDS Nurse E failed to ensure orders, monitoring and instructions for charging and care of the Life Vest were in the chart and a Care Plan was updated for Resident # 1. […]

• Actual harm, isolatedF689Jan 15, 2026

  Based on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident #1) reviewed.The facility failed to ensure that Resident #1 received sufficient supervision to avoid the right femur fracture and subsequent hospitalization on 01/11/26. This failure could place the residents at risk for accidents.Findings included:Review of Resident #1's Face Sheet dated 01/15/26 revealed she was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. […]

• No harm, potential for more than minimal, widespreadF727Jul 9, 2026

  Based on interviews and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 10 of 89 days reviewed for RN coverage.The facility failed to ensure they had an RN on duty on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].This failure placed residents at risk of missed nursing assessments, interventions, care, and treatment.Findings included:Review of the Nursing Master Schedule for the months of January, February, and [DATE] revealed zero hours worked by an RN on the week-end days of [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].In an interview conducted on [DATE] at 4:05 PM, the HR Director reviewed the time sheets for the days that were… […]

• No harm, potential for more than minimal, widespreadF812Mar 29, 2024

  Based on observation, interview, and record review the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen and food sanitation. 1. The facility failed to label and date all food items located in the refrigerators and freezer. 2. The facility failed to ensure damaged or dented canned food items were kept in a separate designated area and not used. 3. The facility failed to ensure kitchen staff practiced proper hand hygiene and glove use when preparing food. 4. The facility failed to ensure kitchen staff cleaned and sanitized the blender in between pureed food items. 5. The facility failed to ensure staff used proper hygienic practice when handling food and feeding a resident. 6. […]

• No harm, potential for more than minimal, patternF656Jul 9, 2026

  Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive care plan that describes the services that are to be furnished to maintain the residents' highest practicable physical, mental, and psychosocial well-being for 3 of 9 residents reviewed for care plans (Resident #9, Resident #53 and Resident #99). 1. The facility failed to ensure Resident #9's comprehensive care plan reflected a plan for her indwelling urinary catheter that included her physician ordered interventions dated 07/02/2026 Urethral catheter (20 Fr) with (30 cc) bulb. […]