Legacy Post Acute Care

Inspectors wroteBased on interview and record review, the facility failed to ensure timely reporting of an abuse allegation incident, to the California Department of Public Health (CDPH), for one of four sampled residents (Resident 1). This failure interfered with the timely investigation of abuse allegation and had the potential to prevent further abuse. The alleged abuse incident occurred on 2/25/26 at around 6 a.m. and the facility reported the incident to CDPH on 2/26/26 at 8:40 a.m.

Inspectors wroteBased on interview and record review, the facility failed to provide Resident 1's requested copies of medical records in a timely manner when Resident 1 submitted a request for his medical records in January 2025 and did not receive the records until June 2025. This failure resulted in a delay in obtaining Resident 1's medical records. Resident 1 received the medical records from the facility three days before a scheduled court date, which did not allow him sufficient time to prepare and share the information with the judge.

Inspectors wroteBased on interview and record review the facility failed ensure that one of six sampled residents' (Resident 69) medical record contained a current copy of Advance Directive (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when the individual is incapacitated). This failure had the potential for Resident 69 to be placed at risk of receiving unwanted treatment and not receiving appropriate care based on his wishes.

Inspectors wroteBased on observation, interview, and record review the facility nursing staff did not accurately complete one out of three residents' (Resident 73) discharge assessment when the wrong discharge disposition was entered. This failure to accurately encode (to enter information into the facility MDS software in the computer) Resident 73's assessment had the potential to not effectively monitor and keep track of resident's progress or decline over time and also cause delay in providing resident information for payment and quality measure purposes.

Inspectors wroteBased on interview and record review, the facility failed to provide a written summary of the baseline care plan to one of five sampled residents (Residents 59) when Resident 59 did not receive a copy of the summary. This failure resulted in Resident 59 to be uninformed of the initial plan of care and services.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain a medication error rate below five percent (5%). During the medication pass on 01/07/25, three medication errors were observed out of twenty-six opportunities for two out of five residents, resulting in an error rate of 11%. This failure had the potential to result in harm in the health and safety of residents.

Inspectors wroteBased on observations, interviews, and record reviews conducted during the assessment, it was identified that the facility did not maintain the medication refrigerator within the required temperature range of 36°F to 46°F, as outlined in their policy. This failure potentially exposes medications to an environment where their efficacy may be compromised due to improper storage conditions. Findings A review of the facility policy, effective December 1, 2007, titled Storage and Expiration Dates of Medications, Biologicals, Syringes, and Needles, indicates that the facility should ensure that medications are stored at appropriate temperatures. Medications requiring refrigeration should be maintained between 36°F and 46°F. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their infection prevention control policy and protocol when nursing staff did not transport one out of five residents' (Resident 21) personal clothes in a clean linen cart used for transportation. The failure had the potential to cause cross contamination and spread of infection among the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and prepared under sanitary conditions when: 1. A kitchen wall and equipment were not clean; 2. Multiple food items were unlabeled, and undated; 3. Staff food was stored in refrigerator #3. This failure had the potential to put residents at risk for cross contamination and food born illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored and labeled appropriately when: 1. Resident 4's expired inhaler and Resident 56's undated opened inhaler were found in medication cart 2. 2. One opened and undated PPD 1 ml. (milliliter, unit of measure) vial was found in medication room in Station 1. 3. The temperature of a room used for medication storage was not being monitored. 4. Loose pills were found in medication cart 3. 5. Two bottles of blood glucose test strips in medication cart 3 were not dated when opened. 6. Four opened unlabeled and undated vials of Insulin (medication to lower blood sugar level) were found in medication cart 3. 7. Resident 21's opened Insulin Kwik Pen (a type of insulin) in medication cart 3 was not dated when opened. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 20 sampled residents (Resident 52, 75 and 233), were notified when the menu changed. This failure had the potential to negatively affect Residents 52, 75 and 233's nutritional intake.

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain a physician's order for the use of an indwelling urinary catheter (a thin sterile tube inserted into the bladder to drain urine to a collection bag outside of the body) for one of 7 sampled residents (Resident 19). This failure had the potential for insufficient and inadequate delivery of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to assure oxygen supplies and equipment were maintained according to policy and the operator's manual for four (4) of five (5) sampled residents (Resident 16, Resident 54, Resident 1, Resident 56). This deficient practice had the potential for the delivery of unclean and inadequate oxygen concentration to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the planned menu when less than stated amount of breaded fish or turkey patty was served to residents receiving regular diets. This failure resulted in residents not getting the prescribed amount of protein for lunch and the potential for weight loss and malnutrition.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to obtain medication for one of four sampled residents (Resident 48) when Isosorbide Mononitrate ER (medication used for heart related chest pain) was not available to administer to Resident 48. The failure to obtain and administer ordered medication had the potential to delay treatment and prolong healing.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure medication error rate of below five percent (%). When: 1. Licensed Vocational Nurse 2 (LVN 2) administered Isosorbide Mononitrate ER (medication used for heart related chest pain) beyond the ordered time frame to Resident 48. 2. Registered Nurse 1 (RN 1) administered regular Aspirin to Resident 48 when the order was Aspirin EC (enteric coated-medicine dissolves in the small intestine instead of stomach to prevent stomach upset) delayed release. These deficient practices placed Resident 48 at risk of developing complications related to error in medication administration.

Inspectors wroteBased on observation and interviews, the facility failed to ensure infection control practice was implemented during medication administration to one of four sampled residents (Resident 65). When Registered Nurse 1 (RN 1) brought the whole bottle of probiotics (live bacteria that are good for the digestive system) inside Resident 65's room. This deficient practice placed residents at risk for contracting infection through medication administration.