Legacy Post Acute Care

In the surveyor’s words

From the most serious findings on record at Legacy Post Acute Care, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Oct 14, 2022

  Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared under sanitary conditions when: 1. A kitchen wall and equipment were not clean; 2. Multiple food items were unlabeled, and undated; 3. Staff food was stored in refrigerator #3. This failure had the potential to put residents at risk for cross contamination and food born illnesses. Findings: During a concurrent observation and interview on 10/10/22, at 09:25 AM, with Dietary Director (DD), the wall behind Refrigerator #2 had dust, and black and gray particles. DD stated, the wall was dirty and needed to be cleaned. The can opener had black and brown particles and residue on the blade and on multiple surfaces. […]

• No harm, potential for more than minimal, patternF761Oct 14, 2022

  Based on observation, interview, and record review, the facility failed to ensure medications were stored and labeled appropriately when: 1. Resident 4's expired inhaler and Resident 56's undated opened inhaler were found in medication cart 2. 2. One opened and undated PPD 1 ml. (milliliter, unit of measure) vial was found in medication room in Station 1. 3. The temperature of a room used for medication storage was not being monitored. 4. Loose pills were found in medication cart 3. 5. Two bottles of blood glucose test strips in medication cart 3 were not dated when opened. 6. Four opened unlabeled and undated vials of Insulin (medication to lower blood sugar level) were found in medication cart 3. 7. […]

• No harm, potential for more than minimal, patternF803Oct 14, 2022

  Based on observation, interview, and record review, the facility failed to ensure three of 20 sampled residents (Resident 52, 75 and 233), were notified when the menu changed. This failure had the potential to negatively affect Residents 52, 75 and 233's nutritional intake. Findings: During an interview on 10/10/22, at 2:51 p.m., with Resident 233, Resident 233 stated, the menu was changed 2-3 times a week, since her admission on 9/18/22. Resident 233 stated, staff didn't tell her when or why the menu changed. Resident 233 stated, on 10/9/22, dinner was a hamburger and potato salad, when the menu had chicken strips in sweet lemon sauce with garlic ginger noodles. Resident 233 stated, on 10/10/22, lunch was a bowl of bean soup, corn bread and salad, when the menu had pot roast and gravy. […]

• No harm, potential for more than minimal, patternF880Feb 2, 2021

  Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program that prevents the spread of Coronavirus Disease 2019 (COVID-19, a contagious infection that can result in severe breathing problems and death) when the following were observed: 1. The facility failed to ensure the Staff/Visitor Pre-Visit Screening Tool (documentation of completion of the entry process and results of the screening of individuals for presence or absence of COVID-19 symptoms) was completed upon entry for four individuals (Certified Nursing Assistant 4, Dietary Aide 1, Visitor 1, Visitor 2, during the time period of 1/18/21 to 1/27/21. 2. […]

• No harm, potential for more than minimal, isolatedF609Apr 3, 2026

  Based on interview and record review, the facility failed to ensure timely reporting of an abuse allegation incident, to the California Department of Public Health (CDPH), for one of four sampled residents (Resident 1). This failure interfered with the timely investigation of abuse allegation and had the potential to prevent further abuse.The alleged abuse incident occurred on 2/25/26 at around 6 a.m. and the facility reported the incident to CDPH on 2/26/26 at 8:40 a.m.Findings:During a review of the facility's abuse incident fax report, dated 2/26/26, the fax report indicated that a report to CDPH was faxed on 2/26/26 at 8:40 a.m. regarding an alleged abuse incident involving Resident 1. […]