Inspection Reports for
Legacy Heights Nursing Home
900 W 12th St, Russellville, AR 72801, United States, AR, 72801
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% better than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
67% occupied
Based on a April 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Deficiencies: 1
Date: Jul 31, 2025
Visit Reason
The inspection was conducted to assess compliance with food safety and infection control standards, specifically focusing on the cleanliness and maintenance of ice machines used in the facility.
Findings
The facility failed to ensure that one of two ice machines was maintained in a clean condition, with observations of an unknown tan and gray substance inside the machine, potentially mold. Interviews revealed inconsistent cleaning practices and unclear training for staff responsible for cleaning the ice machine.
Deficiencies (1)
Failure to ensure ice machines were maintained in a clean condition to minimize the risk for food borne illness.
Report Facts
Cleaning log entries: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide (DA) #1 | Observed wiping the ice machine interior and noted contamination | |
| Housekeeping/Laundry #2 | Responsible for cleaning the ice machine and observed debris on paper towel | |
| Maintenance Director (MD) | Reported monthly cleaning and mechanical checks of the ice machine | |
| Administrator | Provided information on cleaning responsibilities and disposal of contaminated ice | |
| Housekeeping and Laundry Supervisor | Observed debris on paper towel and was trained on ice machine cleaning |
Inspection Report
Deficiencies: 3
Date: Apr 18, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to facility cleanliness, medication discharge procedures, and resident care.
Findings
The facility was found deficient in maintaining cleanliness in one of three shower rooms, failing to document all medications on a resident's discharge summary, and discharging a resident with medications not prescribed to them. These deficiencies were associated with minimal harm and affected a few residents.
Deficiencies (3)
Facility failed to ensure 1 of 3 shower rooms were clean, with feces found on the shower floor.
Facility failed to ensure all medications were documented on the discharge summary for Resident #184.
Resident #184 was discharged with medications not prescribed to them.
Report Facts
Residents affected: 1
Assessment Reference Date: Mar 21, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in medication discharge error where resident was given wrong medications |
| Director of Nursing | Director of Nursing | Interviewed regarding shower room cleaning and medication discharge process |
| Administrator | Administrator | Interviewed regarding shower room cleaning and medication discharge incident |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Observed and interviewed about brown substance on shower floor |
Inspection Report
Routine
Census: 82
Deficiencies: 5
Date: Apr 18, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, food service, and facility safety at Legacy Heights Nursing and Rehab, LLC.
Findings
The facility was found deficient in multiple areas including cleanliness of shower rooms, medication errors upon discharge, unsecured medication storage, improper food preparation and serving practices, and unsanitary kitchen conditions. All deficiencies were assessed as causing minimal harm or potential for actual harm.
Deficiencies (5)
Failed to ensure 1 of 3 shower rooms were clean with feces on the floor.
Failed to ensure all medications were documented on the discharge summary for 1 resident and resident received wrong medications upon discharge.
Medication cart was left unlocked and unattended; controlled narcotics were not stored in locked and affixed container.
Meals were not prepared and served according to the planned menu; pureed food consistency was not smooth.
Food items in refrigerator and freezer were not covered, sealed, or dated; kitchen walls and door frames were damaged; dietary staff failed to wash hands and change gloves appropriately.
Report Facts
Residents affected: 1
Residents affected: 7
Residents affected: 82
Medication syringes: 6
Pureed servings: 7
Food items uncovered: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in medication error finding related to discharge medication mix-up |
| Director of Nursing | Director of Nursing | Interviewed regarding medication discharge process and medication cart security |
| Administrator | Administrator | Interviewed regarding medication errors and facility policies |
| Dietary Employee #2 | Dietary Employee | Observed serving incorrect portion size of pureed food |
| Dietary Employee #5 | Dietary Employee | Observed preparing pureed food with improper consistency and poor hand hygiene |
| Dietary Employee #1 | Dietary Employee | Observed contaminating clean equipment by not washing hands |
| Dietary Employee #3 | Dietary Employee | Observed contaminating clean bowls by not washing hands |
| Dietary Employee #4 | Dietary Employee | Observed handling frozen bread sticks with contaminated gloves |
| Dietary Supervisor | Dietary Supervisor | Interviewed regarding food safety and kitchen sanitation |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about medication cart and emergency kit security |
| Assistant Director of Nursing | Assistant Director of Nursing | Confirmed medication storage deficiencies |
Inspection Report
Routine
Census: 73
Capacity: 122
Deficiencies: 3
Date: Jan 20, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including PASRR screening for mental disorders, food safety and storage practices, and staffing qualifications such as employment of a qualified social worker.
Findings
The facility failed to complete the PASRR evaluation process for residents with serious mental disorders, did not ensure proper labeling and sanitation of food items and equipment in the kitchen, and failed to employ a qualified social worker with the required degree for a facility licensed for more than 120 beds.
Deficiencies (3)
Failed to ensure the PASRR evaluation process was completed for residents with serious mental disorders.
Failed to ensure foods stored in kitchen and resident refrigerators were labeled and dated; cookware was not cleaned and sanitized between uses; ice machine was not maintained in a clean and sanitary condition.
Failed to employ a qualified Social Worker with a minimum of a bachelor's degree in Social Work or a Human Services field for a facility licensed for more than 120 beds.
Report Facts
Residents affected: 1
Residents affected: 73
Residents affected: 73
Facility licensed beds: 122
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SSD [named] | Social Service Director | Named in deficiency for not having required social worker license or bachelor's degree |
| Administrator | Provided information about PASRR process and social worker staffing | |
| Director of Nursing | DON | Provided information about social worker staffing and posted job advertisement |
| Assistant Director of Nursing | ADON | Provided information about PASRR process |
| Assistant Dietary Manager | ADM | Interviewed regarding food storage and sanitation deficiencies |
| Dietary Manager | DM | Interviewed regarding food handling practices |
| HR Employee | Provided documentation and information about Social Service Director qualifications |
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