Legacy Village Rehabilitation

In the surveyor’s words

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

• Actual harm, isolatedF580Dec 1, 2025

  Based on interview and record review it was determined, for 1 out of 5 sampled residents, that the facility did not immediately consult with the resident's physician when there was a significant change in the resident's physical status or a need to alter treatment. Specifically, a resident experienced a change in condition after a fall and the medical provider was not notified of the change timely. This resulted in a finding of harm to the resident. Resident identifier: 2.Findings included: Resident 2 was admitted to the facility on [DATE] with diagnoses which included, traumatic subarachnoid hemorrhage, nontraumatic acute subdural hemorrhage, difficulty in walking, epileptic seizures, and obstructive hydrocephalus.Resident 2's medical record was reviewed on 12/1/25. […]

• Actual harm, isolatedF684Dec 1, 2025

  Based on interview and record review it was determined, for 1 out of 5 sampled residents, that the facility did not ensure residents received treatment and care in accordance with professional standards of practice. Specifically, a resident sustained a fall, experienced a change in condition and the physician was not notified. Additionally, when the physician assessed the resident the resident was sent to the emergency room where she was diagnosed with a brain bleed and passed away four days later. This resulted in a finding of harm for the resident. […]

• No harm, potential for more than minimal, patternF640May 27, 2026

  Based on interview and record review, for 9 of 25 sampled residents, the facility did not transmit completed Minimum Data Set (MDS) to the CMS (Center for Medicare/Medicaid Services) for discharge assessment within 14 days. Specifically, residents discharged MDS's were not signed by a Registered Nurse and transmitted within the required timeframe. In addition, one resident was discharged and did not have a discharge assessment. Resident identifier: 1, 2, 3, 4, 5, 13, 44, 58 and 66. Findings included:1. Resident 1 was admitted to the facility on [DATE] and discharged on 4/10/26 with diagnoses which included sepsis, heart failure and altered mental status. Resident 1 had a Minimum Data Set (MDS) with an assessment reference date of 4/10/26 for discharge with return not anticipated. […]

• No harm, potential for more than minimal, patternF640May 15, 2025

  Based on interview and record review, it was determined that for 16 of 40 sampled residents, that the facility did not electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the CMS System. Specifically, the facility did not electronically transmit 16 discharge MDS assessments to the CMS System. Resident Identifiers: 4, 10, 12, 30, 42, 46, 54, 62, 64, 68, 69, 70, 71, 72, 73, and 75. Findings Include: Minimum Data Set (MDS) Assessments and medical records were reviewed from 5/12/25 through 5/15/25 for residents 4, 10, 12, 30, 42, 46, 54, 62, 64, 68, 69, 70, 71, 72, 73, and 75. Resident 4's discharge assessment date was 1/4/25. Resident 10's discharge assessment date was 1/21/25. Resident 12's discharge assessment date was 4/7/25. […]

• No harm, potential for more than minimal, patternF880Aug 30, 2023

  Based on observation and interview, it was determined, that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, meal tray items were uncovered when delivered by staff throughout resident hallways. Findings Included: 1. Lunch meal trays, which included, uncovered desserts were transported through resident hallway 200. […]