The Legacy Rehab & Care Center

In the surveyor’s words

From the most serious findings on record at The Legacy Rehab & Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF921Feb 9, 2023

  Based on observations, staff interviews and review of facility policy the facility failed to ensure that hot was temperatures remained in the safe range in the resident rooms. Findings include: During the initial screening of the residents conducted on February 6, 2023 at 2:03 PM, the water temperatures at the restroom sink in room [ROOM NUMBER] was checked and it was 130.6 degrees F. The resident was unable to use the sink. During the initial screening of the residents conducted on February 6, 2023 at 2:15 PM, the water temperature at the restroom sink in room [ROOM NUMBER] was checked and it was 131.4 degrees F. […]

• No harm, potential for more than minimal, patternF880Dec 2, 2021

  Based on an observation, staff interviews, and facility policy, the facility failed to maintain infection prevention and control when delivering meal trays. The census was 46 residents. The deficient practice could result in transmission of infection, including COVID-19, within the facility. Findings include: An observation was conducted on November 30, 2021 of a dietary server (staff #12) delivering in-room lunch meal trays to 10 residents. The following was observed: -In a room, the staff member picked up and moved the television remote and moved the bedside table before placing the meal tray on the bedside table. -In another room, the staff member picked up and moved a cup that was on the bedside table before placing the meal tray on the bedside table. […]

• No harm, potential for more than minimal, isolatedF689May 15, 2026

  Based on staff and resident interviews, review of facility documentation, and review of facility policies and procedures the facility failed to ensure residents were free from avoidable accidents related to transportation for 1 of 18 sampled residents (resident #44). The universe was 85. The deficient practice could lead to potential avoidable injuries. Findings include: Resident #44 was re-admitted to the facility on [DATE] with diagnoses of unspecified gangrene, acute kidney failure, and acute respiratory failure. The revised care plan dated April 30, 2026 revealed a problem related to potential injuries from falls. Interventions included to assist in ambulating and transferring, and to observe, record and correct all unsafe conditions. […]

• No harm, potential for more than minimal, isolatedF628Sep 9, 2025

  Based on closed record review, staff interviews, and review of facility policy, the facility failed to ensure that discharge notifications were made for one of seven residents (#16) to the representative of the Office of the State Long-Term Care Ombudsman. The deficient practice can result in further notifications of resident discharge not being provided to the Ombudsman.Findings include:Resident #16 was admitted on [DATE], and discharged on November 19, 2023, with the diagnosis that included unspecified fracture of the lower end of the right femur, subsequent encounter for closed fracture with routine healing.A baseline care plan with the initiation date of November 10, 2023, revealed that Resident #16 will receive the necessary therapy services to return home safely.An admission MDS… […]

• No harm, potential for more than minimal, isolatedF645Feb 9, 2023

  Based on clinical record review, staff interviews and review of facility policy, the facility failed to ensure that a required Pre-Admission Screening and Resident Review Level II was completed for one resident (#3). Findings include: Review of the clinical record revealed a Pre-Admission Screening and Resident Review Level 1 dated September 17, 2021 which indicated a need for a Level II determination for Mental Illness. Additionally there was an email from the resident's case manager dated September 10mg 2021 which stated that the resident should have a Level II assessment completed. […]