Legacy Rehabilitation and Living

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received care and treatment, consistent with professional standards of practice, to ensure residents assessed for pressure ulcers received treatment and care to prevent pressure ulcers from developing for 1 of 10 residents (Resident #1) reviewed for pressure ulcers. LVN A failed to change Resident #1 pressure ulcer dressings on both her ankles 3 times. Resident #1's dressing changes were ordered every Monday, Wednesday and Friday and PRN. The dressings on Resident #1's ankles were dated 7/12/26 (Sunday). The dressings were not changed on 7/13/26, 7/15/26 and 7/17/26. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to 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 disease and infections for 1 of 10 residents (Resident #1) observed for infection control. The facility failed on 7/18/26 when LVN A failed to wash hands or change gloves while providing wound care to Resident #1. This failure could place residents at risk for the spread of infections, tissue breakdown and or worsening of wounds or pressure ulcers.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the resident's environment remained as free from accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 2 residents reviewed for accident hazards. The facility failed to ensure Resident #1 was properly secured/fastened in the facility van resulting in bodily injury to the head, arm, stomach, and leg of Resident #1. An Immediate Jeopardy (IJ) was identified on 05/04/2026 at 4:47 PM. The IJ template was provided to the OM on 05/04/2026 at 5:21 PM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to report to the State Survey Agency an allegation of neglect involving a fall with injury within 2 hours of the allegation for 1 (Resident #1) of 1 resident. The facility failed to report a fall with an injury on [DATE] for Resident #1. This failure could place residents at risk of not having incidents of abuse, neglect, exploitation, and misappropriation of resident property being reviewed and investigated in a timely manner by the facility and state survey agency. This could place residents at risk of continued and/or unrecognized abuse, neglect, or exploitation. Findings Included:Resident #1Record review of Resident #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the governing body of the facility had appointed an Administrator, who is licensed by the state, to be responsible for the management of the facility and report to the governing body. The facility had not had an Administrator since March 2026. This deficient practice could place residents at risk of decreased quality of life and quality of care due to lack of staff oversight and monitoring of care for all 128 residents at the facility.

Inspectors wroteBased on interview, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #1) of 8 residents reviewed for respiratory care. The facility failed to ensure Resident #1 received O2 via NC continuously as ordered by her physician. This failure could place residents who receive oxygen at an increased risk of hypoxemia (low levels of oxygen in the blood, decreasing the oxygen supply to vital organs), and shortness of breath. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 (Resident #1) of 8 residents reviewed for unnecessary drugs. The facility failed to discontinue 4 medications (mirtazapine, escitalopram, tizanidine, and tramadol) as documented in the physician orders in Resident #1's hospital discharge records dated 08/01/25. This failure could place residents at risk of harm due to medication side effects and/or medication interactions. Findings Included:Record review of Resident #1's admission record dated 09/09/25 revealed a [AGE] year-old female admitted to the facility on [DATE] from an acute care hospital. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility through a means other than the postal service for 13 of 13 anonymous residents reviewed for Resident Rights The facility failed to ensure mail and packages from the U.S Postal Service were delivered to residents on Saturdays. The facility failed to ensure mail and packages delivered by means other than the postal service were delivered to residents on Saturdays and Sundays. These failures could cause residents to experience loneliness, depression, missing property and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 for 3 (LVN A, CNA B, and CNA C) of 6 staff observed for resident care LVN A did not wear a gown when administering medications through Resident #11. CNA A and CNA B did not wear a gown when providing catheter care for Resident #86. This deficient practice could place residents at risk of cross-contamination and infections.

Inspectors wroteBased on interview, record review, the facility failed to report an alleged violation of abuse/neglect immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation resulted in serious bodily injury, to officials in accordance with State law, including to the State Survey Agency for one (Resident #1) of 9 residents reviewed for abuse/neglect. The facility failed to report that Resident #1 alleged that she had been raped on 1-22-2025. The noncompliance was found to be Past Non-Compliance (PNC). The noncompliance began on 1-22-2024 and ended on 2-2-2024. The facility corrected the noncompliance before the investigation began. This failure could result in delayed identification of abuse or neglect and lack of timely follow-up on recommended interventions to prevent serious bodily harm, or lasting physical impairment.

Inspectors wroteBased on observation, interview, and record review; the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 2 of 3 medication carts (2C-1 and 100 Skilled medication carts) observed. -1 loose pill (Meloxicam)discovered in 2C-1 medication cart. -2 loose pills (Flexeril and unidentified pill) and a packet of 50 (Methadone) pills not double locked. These failures could result in residents' medications not being properly stored and maintained at their best therapeutic level.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the menu was followed, for 2 out of 5 residents that received pureed food (Resident # 19 and 21), and one resident (#16) who had a mechanical soft diet in the Alzheimer's unit in that: 1. The facility failed to ensure Resident # 19 received a pureed pancake for breakfast on 6/5/24. 2. The facility failed to ensure Resident #16 received toast with her breakfast on 6/5/24. 3. Residents #16, 19 and # 21 received pudding for the lunch dessert instead of cream pie and pudding for the supper meal instead of the chocolate chip cookie the other residents received for 6/5/24. Residents #16,19 and 21 did not receive sweet potato casserole for lunch. 4. Residents #16, 19 and #21 received pudding for the lunch meal on 6/6/24 instead of the dessert empanada. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 21 residents (Resident #94) reviewed for resident's rights. -CNA A was standing next to Resident #94's Geri-chair while feeding resident his lunch time meal. This failure could cause residents to feel humiliated and disrespected.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to and the facility promoted and facilitated resident self-determination through support of resident choice, which included but not limited to the right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 25 residents (Resident #21) reviewed for self-determination. The facility failed to ensure Resident #21 was allowed to choose the type of foods he preferred when he expressed he would like all the foods the other residents were served. This failure could place residents at risk for being denied the opportunity to exercise his or her autonomy regarding things that were important in their life and a decrease in their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #5) of 21 residents reviewed for respiratory care. The facility failed to change Resident #5's nebulizer tubing and mask as per his physician orders. This failure could affect residents on respiratory therapy by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, and exacerbation of their condition.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents had the right to reasonable access to the use of a telephone, and a place in the facility where calls can be made without being overheard for 9 of 99 (Residents #1, #2, #3, #4, #5, #6, #7, #8, and #9) residents reviewed for Resident Rights. Residents #1, #2, #3, #4, #5, #6, #7, #8 and #9 stated they did not have access to a telephone to make private calls. This failure could place residents at risk of increased social isolation and decreased psychosocial well-being. Findings Included: Resident #1 In an interview on 5/17/24 at 8:49AM Resident #1 stated he had been at the facility about a year and when he arrived, he had a personal cell phone to use to communicate with friends and family outside of the facility. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 or 10 residents (Resident #1) reviewed for care plans . The facility failed to ensure that Resident #1's care plan was implemented correctly according to her needs. This failure could place residents at risk for not receiving the necessary care or receiving inappropriate care for their condition and diagnosis.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in the facility kitchen reviewed for dietary services in that: There was unlabeled, undated, and unsealed food in the refrigerators, freezers, and dry storage area; there was expired food in the refrigerators, freezer, and dry storage area; staff's personal food was in one of the service refrigerators; and refrigerator and freezer temperature logs were not updated. These failures placed residents who ate food served by the kitchen at risk for food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and 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 for 3 of 3 staff (CNA I, CNA J, and MA F) reviewed for infection control. The facility failed to ensure that CNA I, CNA J, and MA F performed hand hygiene appropriately during overall care of residents, this including medication pass. This failure could place the residents at an increased risk for potentially exposing them to viral infections, secondary infections, tissue breakdown, communicable diseases and feelings of isolation related to poor hygiene.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life by failing to assure dignity and respect were provided for 2 of 2 residents (Resident #11 and Resident #67) reviewed for privacy and dignity issues. Resident #11 and Resident #67's abdomens were exposed in the multi-purpose room of the locked unit during their subcutaneous injection of insulin, that was administered by LVN D. This failure could cause residents to feel uncomfortable and disrespected.

Inspectors wroteBased on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 2 (Resident #34, and #67) of 23 residents reviewed for advanced directives. Resident #34 and Resident #67 had a DNRs in their records that were incomplete, missing information and signatures. The facility's failure to ensure the accuracy of a residents advanced directive such as a DNR (Do Not Resuscitate), recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care could place residents a risk for not receiving healthcare as per their or their legal representatives wishes.

Inspectors wroteBased on observation, interview, and record review the facility failed to conduct a comprehensive and accurate assessment of each resident using the resident assessment instrument (RAI) specified by CMS for 2 (Resident #58 and #79) of 23 residents whose records were reviewed for assessments. Resident #58 and Resident #79 did not have section C completed on their last MDS assessment. This failure to ensure comprehensive and accurate assessments could affect all residents by placing them at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed, based on a resident's comprehensive assessment, to ensure that a resident is offered a therapeutic diet when there is a nutritional problem, and the health care provider orders a therapeutic diet for 2 (Resident #23 and Resident #208) of 23 residents reviewed for nutrition. Residents #23 and #208 had physician's orders for therapeutic diets, but the dietary staff did not have them listed as receiving therapeutic diets. This failure could place residents who are to receive therapeutic diets at risk of not receiving the diets as ordered and could result in health complications such as increased sugar, waste and build up in the blood stream due to inappropriate nutrition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences, for 1 (Resident #208) of 23 residents reviewed for respiratory care. Resident #208 had orders for oxygen at 2 liters per minute and was receiving oxygen at higher concentrations. This failure could place residents who receive oxygen at an increased risk for receiving oxygen at the wrong rate which could lead to hypercapnia (too much carbon dioxide in the blood), pulmonary oxygen toxicity (damage to the lung lining tissues and air sacs), hypoxemia (low levels of oxygen in the blood, decreasing the oxygen supply to vital organs), and shortness of breath.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 3 of 3 medications. Omeprazpole, Vitamin D3 5000IU, and Dronabinol The facility failed to ensure that medications have an expiration date and/or are discarded appropriately and in a timely manner after medication has expired. This failure could place residents at risk for reduced efficacy of the medications administered.