Legacy Rehabilitation and Living

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689May 5, 2026

  Based on observation, interview and record review, the facility failed to ensure that the resident's environment remained as free from accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 2 residents reviewed for accident hazards. The facility failed to ensure Resident #1 was properly secured/fastened in the facility van resulting in bodily injury to the head, arm, stomach, and leg of Resident #1. An Immediate Jeopardy (IJ) was identified on 05/04/2026 at 4:47 PM. The IJ template was provided to the OM on 05/04/2026 at 5:21 PM. […]

• Immediate jeopardy, isolatedF684Aug 25, 2021

  Based on observations, interviews and record review, it was determined the facility failed to ensure that residents received treatment and care in accordance with the professional standards of practice and comprehensive person-centered care plan for 1 of 7 residents (Resident #1) reviewed for care provided. The facility failed to ensure Resident #1's wound orders for 8/4/21 for dressing changes for a surgical incision to her left ankle were implemented and/or provided for 14 days. Van Driver failed to give the dressing change orders from Resident #1's follow-up appointment with the surgeon to LVN A who was taking care of Resident #1. In addition, LVN A failed to follow-up with the physician to see if there were any orders for Resident #1's surgical incision. […]

• No harm, potential for more than minimal, widespreadF812Apr 14, 2023

  Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in the facility kitchen reviewed for dietary services in that: There was unlabeled, undated, and unsealed food in the refrigerators, freezers, and dry storage area; there was expired food in the refrigerators, freezer, and dry storage area; staff's personal food was in one of the service refrigerators; and refrigerator and freezer temperature logs were not updated. These failures placed residents who ate food served by the kitchen at risk for food-borne illness. Findings include: In an observation of the kitchen and refrigerator on [DATE] at 8:10 AM the following was observed: 1. […]

• No harm, potential for more than minimal, widespreadF812Mar 9, 2022

  Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to: Ensure foods were stored, prepared and served under sanitary conditions. These failures may increase the risk for foodborne illness. Findings include: In an observation on 03/07/22 at 08:30 AM the following issues in the pantry were observed: 1. Crumbs and dirt on top of buckets holding flour, sugar, brown sugar and rice. 2. Bucket of sugar on floor in storage In an observation on 03/07/22 at 08:30 AM the following issues in the kitchen were observed: 1. Crumbs on toaster 2. Crumbs behind toaster 3. Crumbs behind microwave 4. Crumbs on stove 5. […]

• No harm, potential for more than minimal, widespreadF812Apr 13, 2021

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food under sanitary conditions in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed. A. The facility failed to ensure kitchen personnel wore face masks in the facility and while preparing food during the COVID-19 pandemic. B. The facility failed to ensure kitchen staff used proper hand washing and sanitation procedures when handling food. These failures could place residents who eat food served by the facility's only kitchen at risk of cross contamination and food-borne illness. Findings included: During an observation on 4/11/21 at 8:57 AM, CK H was observed walking around the kitchen prep area with her mask down under her chin. […]