Inspection Reports for
Legacy Senior Living
1020 S Scott Blvd, Iowa City, IA 52240, IA, 52240
Back to Facility Profile7 Reports
Inspection Report — Nov 20, 2025
Renewal
Date: Nov 20, 2025
Visit Reason
This was a standard recertification visit to determine compliance with certification rules for an Assisted Living Program.
Findings
Multiple regulatory insufficiencies were cited related to medication documentation and administration, nurse delegation communication, tenant evaluations, tenant documentation, and service plans.
Violations (6)
481-67.5(2)f(3) Medications: The program failed to document medications administered for sliding scale insulin for Tenant #1, including the number of units given and blood glucose values at times.
481-67.5(2)f(4) Medications: The program failed to administer insulin as ordered for Tenant #1, with observed deviations from the prescribed medication pass.
481-67.9(4)g Staffing: The program failed to document in writing occurrences that differed from tenants' normal health, functional, and cognitive status for 1 of 6 tenants reviewed and potentially others.
481-69.22(3) Evaluation of Tenant: The program failed to complete evaluations as needed with significant change for Tenant #3.
481-69.25(1)i Tenant Documents: The program failed to document nurses' notes by exception for 3 of 6 tenants reviewed, including incomplete records of transitions, incidents, and medication therapy.
481-69.26(1) Service Plans: The program failed to update service plans as needed for 5 of 6 tenants reviewed, missing current medication administration, care refusals, and nutritional preferences.
Inspection Report — May 14, 2025
Complaint Investigation
Date: May 14, 2025
Visit Reason
Investigation of Incident #126892-I at the assisted living facility Legacy Pointe.
Complaint Details
Investigation of Incident #126892-I found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of Incident #126892-I.
Report Facts
Number of tenants without cognitive impairment: 64
Number of tenants with cognitive impairment: 7
Inspection Report — May 14, 2024
Complaint Investigation
Date: May 14, 2024
Visit Reason
The inspection was conducted as an investigation of Complaints #119003-C and #120010-C related to tenant care and service adequacy.
Complaint Details
The investigation was triggered by complaints #119003-C and #120010-C. Tenant C1's care related to COVID-19 and code status was substantiated as deficient. Tenant C2's evaluations and service plans were found deficient. Food service temperature violations were also noted.
Findings
The Program failed to provide adequate and appropriate care related to a tenant's COVID-19 diagnosis and symptoms, failed to complete evaluations as needed for another tenant, failed to update service plans to reflect tenant needs, and failed to maintain cold beverage temperatures at safe levels.
Violations (4)
Failure to provide adequate and appropriate care related to COVID-19 diagnosis and symptoms for Tenant C1, including lack of vital sign monitoring and conflicting code status information sent to hospital.
Failure to complete evaluations as needed for Tenant C2 related to increased assistance requirements and pain.
Failure to update service plans to reflect Tenant C2's increased assistance needs and pain.
Failure to maintain cold beverages at safe temperatures; milk was found at 53-54 degrees instead of 41 degrees or below.
Report Facts
Oxygen saturation: 51
Pulse: 113
Respiration rate: 32
Milk temperature: 53.2
Milk temperature: 54.2
Date survey completed: May 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Olivia English | Director of Nursing | Named in interviews related to Tenant C1 and Tenant C2 care and evaluations |
| Robert Walton | Resource Nurse | Named in plan of correction re-education |
| Julie Reynolds | Assistant Director of Nursing | Named in interviews related to Tenant C1 care and plan of correction re-education |
| Jacobi Feckers | Executive Director | Named in plan of correction re-education and interviews |
| Morgan Fox | Regional Manager-Health Services | Named in plan of correction re-education and monitoring |
| Jake Paul | Dining Director | Named in food service temperature deficiency and plan of correction |
| Kati Montgomery | Dining Room Supervisor | Named in food service temperature deficiency and plan of correction |
Inspection Report — May 6, 2024
Enforcement
Date: May 6, 2024
Visit Reason
This citation resulted from investigations 119223-C and 120010-C conducted from May 6 to May 14, 2024, concerning care deficiencies related to a COVID-19 positive tenant (Tenant C1) and issues with code status communication to the hospital.
Complaint Details
Investigations 119223-C and 120010-C
Findings
The program failed to provide adequate and appropriate care related to Tenant C1's COVID-19 diagnosis and symptoms, including lack of documented vital signs during isolation and conflicting resuscitation status information sent to the hospital. Tenant C1 was found injured and hypoxic, transported to the hospital, and died there.
Violations (1)
481-67.3(2) Tenant rights: The program failed to provide adequate and appropriate care related to Tenant C1's COVID-19 diagnosis and symptoms, including no documented vital signs during isolation and failure to communicate the correct DNR/DNI code status to the hospital.
Report Facts
Fine amount: 2500
Inspection Report — Jul 12, 2023
Renewal
Date: Jul 12, 2023
Visit Reason
The visit was a recertification inspection conducted to determine compliance with certification rules for an Assisted Living Program and to investigate specific incidents and a complaint.
Complaint Details
The investigation included Incidents #109712-I, #110621-I, #111254-I and Complaint #113983-C; no deficiencies were found.
Findings
No regulatory insufficiencies were cited during the recertification visit and investigation of incidents and complaint.
Report Facts
Number of tenants without cognitive impairment: 61
Number of tenants with cognitive impairment: 10
Inspection Report — Nov 16, 2022
Complaint Investigation
Date: Nov 16, 2022
Visit Reason
Investigation of Incident # 100481-C at the assisted living facility.
Complaint Details
Investigation of Incident # 100481-C with no regulatory insufficiencies cited.
Findings
No regulatory insufficiencies were cited during the investigation of the incident.
Report Facts
Number of tenants without cognitive impairment: 60
Number of tenants with cognitive impairment: 5
Inspection Report — Apr 13, 2021
Annual Inspection
Date: Apr 13, 2021
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification for an Assisted Living Program.
Findings
The inspection identified regulatory insufficiencies related to nurse delegation training not completed within 30 days of employment for 5 staff, invalid background check for 1 staff member, and failure to develop individualized service plans reflecting tenants' identified needs and preferences for assistance for 2 tenants.
Violations (3)
Failed to complete nurse delegated training within 30 days of employment for 5 direct care staff.
Failed to complete a valid background check prior to employment for 1 staff member.
Failed to develop individualized service plans reflecting tenants' identified needs and preferences for assistance for 2 tenants.
Report Facts
Number of tenants without cognitive disorder: 45
Number of tenants with cognitive disorder: 3
Direct care staff with late nurse delegation training: 5
Staff reviewed for valid background check: 7
Tenants with incomplete service plans: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacobi Feckers | Executive Director | Signed the Plan of Correction and confirmed findings during interview. |
| Shawn Anderson | Director of Nursing | Confirmed nurse delegation documents and service plan findings during interviews. |
| Erica Ewoldt | Director of Health Services | Mentioned in Plan of Correction for training and monitoring compliance. |
| Jessica German | Team Member Experience Director | Mentioned in Plan of Correction for training related to background checks. |
| Staff A | Direct care staff with late nurse delegation training and invalid background check. | |
| Staff B | Direct care staff with late nurse delegation training. | |
| Staff C | Direct care staff with late nurse delegation training. | |
| Staff D | Direct care staff with late nurse delegation training. | |
| Staff E | Direct care staff with late nurse delegation training. | |
| Staff F | Staff who reported Tenant #5's comments regarding not wanting to live. | |
| Kelly Newcomb | Assistant Director of Nursing | Mentioned in Plan of Correction for training related to service plans. |
Viewing
Loading inspection reports...
