The Legacy Living and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jan 17, 2025

  Based on observation, medical record review, staff interview, closed-circuit camera review, and policy and procedure review, the facility failed to protect the resident's right to be free from neglect for 1 of 3 sample residents (#6) reviewed for abuse and neglect. This failure resulted in the death of resident #6 who exited the facility without being noticed and was outside in winter weather conditions for 9 hours and 17 minutes. This failure resulted in the determination of immediate jeopardy due to the lack of necessary services to ensure residents' safety. On [DATE] there were 19 residents on the Cottonwood and Pine units who were identified as high-risk for wandering/elopement. Corrective measures were implemented prior to the survey and compliance was determined to be met on [DATE]. […]

• Immediate jeopardy, isolatedF689Jan 17, 2025

  Based on medical record review, staff interview, closed-circuit camera review, and policy and procedure review, the facility failed ensure residents received adequate supervision to prevent accidents for 1 of 3 sample residents (#6) reviewed for accident hazards. This failure resulted in the death of resident #6 who exited the facility without being noticed and was outside in winter weather conditions for 9 hours and 17 minutes. This failure resulted in the determination of immediate jeopardy due to a lack of implementation of interventions, including adequate resident supervision. On [DATE] there were 19 residents on the Cottonwood and Pine units who were identified as high-risk for wandering/elopement. […]

• Actual harm, isolatedF600Apr 15, 2025

  Based on observation, staff interview, medical record review, facility incident investigation review, and performance improvement plan review, the facility failed to protect the resident's right to be free from physical abuse by a resident for 3 of 4 sample residents (#1, #3, #5) involved in a resident-to-resident altercation. This failure resulted in actual harm to resident #1 who suffered a hematoma above his/her left eyebrow and an abrasion under his/her left eye. The facility implemented corrective action prior to the survey and was determined to be in substantial compliance as of 4/8/25. The findings were: 1. […]

• Actual harm, isolatedF684Jan 17, 2025

  Based on medical record review and physician and staff interview, the facility failed to respond to a change of condition for 1 of 4 sample residents (#3) who experienced a change of condition. This failure resulted in actual harm to resident #3 who reported health concerns and passed away. The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #3 had a brief interview for mental status score of 15 out of 15, which indicated the resident was cognitively intact, and diagnoses which included heart failure, hypertension, peripheral vascular disease, diabetes mellitus, cerebrovascular accident, anxiety disorder, depression, and asthma. Further review showed the resident required supervision or touching assistance with transfer and toileting hygiene. […]

• Actual harm, isolatedF600Jun 19, 2024

  Based on medical record review, resident representative and staff interview, facility investigation review, and policy and procedure review, the facility failed to ensure a resident's right to be free from physical abuse, verbal abuse, and neglect for 1 of 6 sample residents (#1). The findings were: The facility had implemented corrective action prior to the survey and was determined to be in substantial compliance as of 6/18/24. 1. Review of a quarterly MDS assessment dated [DATE] showed resident #1 had brief interview for mental status (BIMS) score of 3 out of 15, which indicated severe cognitive impairment. […]