Legacy Square

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Oct 23, 2025

  Licensure Reference Number 175 NAC 12-006.09(I)Based on record review and interview, the facility failed to prevent an elopement which had the potential to cause harm on one resident (Resident 1) out of three residents sampled. This had the potential to affect six residents identified at risk for elopement. The facility census was 37. Findings:The facility was notified on 10/20/2025 at 5:02 PM of an Immediate Jeopardy (IJ represents a situation in which noncompliance by the facility has placed the health and safety of the residents in its care at risk for serious injury, serious harm, serious impairment, or death) which began on 10/13/2025. […]

• No harm, potential for more than minimal, widespreadF812Jan 15, 2026

  Licensure Reference Number 175 NAC 12-006.11EBased on observations, record reviews and interviews, the facility failed to ensure hand hygiene was completed and hair was restrained during meal service. This failure had the potential to affect all 32 residents receiving meals from the kitchen. The facility census was 33 at the time of survey. Findings are:Record review of 2022 Food Code revealed the following:-2-301.12 FOOD EMPLOYEES shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a HANDWASHING SINK that is equipped as specified under S 5-202.12 and Subpart 6-301. […]

• No harm, potential for more than minimal, widespreadF880Jan 15, 2026

  Licensure Reference Number 175 NAC 12-006.18(B)Based on observations, interviews, and record reviews, the facility failed to prevent cross-contamination of COVID-19 (an infectious disease that is highly contagious) between 10 residents (Resident 2, 3, 8, 12,14, 15, 18, 22, 24, and Resident 30) out of 22 sampled residents. The facility census was 33 at the time of the survey. Findings are: A record review of the Facility Assessment with a Quality Assessment Committee review date of June 2025, under part two revealed: Offers care based on the resident's needs Offers infection prevention and control by identifying, containing, and preventing infections Offers management of medical conditions by assessment and early identification of medical symptoms, including infections A record review of… […]

• No harm, potential for more than minimal, widespreadF882Jan 15, 2026

  Licensure Reference Number 175 NAC Chapter 1-005.06(H)Based on interviews and record reviews, the facility failed to designate a dedicated staff member as the infection preventionist who is responsible for the facility's infection prevention and control program that works at least part-time. This had the potential to affect 33 residents that resided in the facility at the time of the survey. The facility census was 33.Findings are: A record review of the Laboratory Supervisor/Infection Preventionist Job Description (JD) dated 8.21.2025 revealed responsibilities to include the identification, investigation, reporting, prevention and control of infections, and communicable diseases within the organization. […]

• No harm, potential for more than minimal, widespreadF868Oct 23, 2025

  Licensure Reference Number 175 NAC 12-006.07ABased on interviews and record review, the facility administrator failed to ensure the Quality Assessment and Assurance (QAA) committee included all of the required members. This had the potential to affect all of the residents in the facility. The facility census was 37 at the time of the survey.Findings are:Record review of the facility's Quality Assurance (QA) meeting records revealed no evidence of the facility's Medical Director had participated in the quarterly QA meetings in the facility for the past 4 quarters on December 17, 2024, March 18, 2025, June 17, 2025, and September 16, 2025.During an interview on 10/23/2025 at 10:28 AM the Assistant Administrator confirmed there was no documentation that the facility's Medical Director had… […]