Inspection Reports for Legacy Senior Living
1020 S Scott Blvd, Iowa City, IA 52240, IA, 52240
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 14, 2025, found no deficiencies during a complaint investigation. Earlier inspections showed a mixed record, with several reports citing deficiencies related primarily to tenant care, service plan updates, and staff training, including a substantiated complaint in May 2024 involving inadequate COVID-19 care and food temperature issues. Prior complaint investigations were mostly unsubstantiated, and enforcement actions were limited to a $500 fine in 2009 for a late accident report; no license suspensions or immediate jeopardy findings were listed in the available reports. The facility demonstrated improvement in recent years, with no deficiencies noted in the latest inspections after earlier issues. Complaint investigations generally did not find regulatory insufficiencies, indicating some progress in compliance over time.
Deficiencies (last 14 years)
Deficiencies (over 14 years)
1.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
70% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
71 residents
Based on a May 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 0
May 14, 2025
Visit Reason
Investigation of Incident #126892-I at the assisted living facility Legacy Pointe.
Findings
No regulatory insufficiencies were cited during the investigation of Incident #126892-I.
Complaint Details
Investigation of Incident #126892-I found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive impairment: 64
Number of tenants with cognitive impairment: 7
Total census: 71
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 4
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.
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.
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.
Deficiencies (4)
| Description |
|---|
| 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
Total census: 70
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
Renewal
Census: 71
Deficiencies: 0
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.
Findings
No regulatory insufficiencies were cited during the recertification visit and investigation of incidents and complaint.
Complaint Details
The investigation included Incidents #109712-I, #110621-I, #111254-I and Complaint #113983-C; no deficiencies were found.
Report Facts
Number of tenants without cognitive impairment: 61
Number of tenants with cognitive impairment: 10
Total census: 71
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 0
Nov 16, 2022
Visit Reason
Investigation of Incident # 100481-C at the assisted living facility.
Findings
No regulatory insufficiencies were cited during the investigation of the incident.
Complaint Details
Investigation of Incident # 100481-C with no regulatory insufficiencies cited.
Report Facts
Number of tenants without cognitive impairment: 60
Number of tenants with cognitive impairment: 5
Total census: 65
Inspection Report
Annual Inspection
Census: 48
Deficiencies: 3
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.
Deficiencies (3)
| Description |
|---|
| 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
Total census: 48
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. |
Inspection Report
Renewal
Census: 47
Deficiencies: 0
Apr 29, 2019
Visit Reason
Recertification visit to determine compliance with the licensing rules for an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification visit for the Assisted Living Program.
Report Facts
Number of tenants without cognitive disorder: 45
Number of tenants with cognitive disorder: 2
Total census: 47
Inspection Report
Renewal
Census: 70
Deficiencies: 0
Mar 21, 2017
Visit Reason
Recertification visit conducted to determine compliance with certification for an Assisted Living Program (ALP).
Findings
No regulatory insufficiencies were cited during the recertification visit for the Assisted Living Program.
Report Facts
Number of tenants without cognitive disorder: 65
Number of tenants with cognitive disorder: 5
Total Population of Program at time of on-site: 70
TOTAL census of Assisted Living Program: 70
Inspection Report
Plan of Correction
Census: 66
Deficiencies: 0
Jan 18, 2017
Visit Reason
The visit was conducted as a plan of correction following investigation of incidents #64006-I and #64625-I.
Findings
No regulatory insufficiencies were cited during the investigation of the incidents.
Report Facts
Number of tenants without cognitive disorder: 61
Number of tenants with cognitive disorder: 5
Total Population of Program at time of onsite: 66
TOTAL census of Assisted Living Program: 66
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 0
Mar 2, 2016
Visit Reason
The inspection was conducted as a complaint/incident investigation following Complaint/Incident Intake #57802-C on March 1 and 2, 2016.
Findings
No regulatory insufficiencies were cited during the investigation of Complaint #57802-C. The State Fire Marshal approved the alarm system for the dementia-specific program, and the regulatory insufficiency was removed.
Complaint Details
Complaint/Incident Intake #57802-C was investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 66
Number of tenants with cognitive disorder: 7
Total Population of Program at time of on-site: 73
TOTAL census of Assisted Living Program: 73
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator, Adult Services Bureau | Author of the cover letter regarding the amended final complaint/incident investigation report |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 0
Jan 25, 2016
Visit Reason
The inspection was conducted as a final complaint/incident investigation for Legacy Pointe in Iowa City, IA, following a complaint intake #56587-C.
Findings
No regulatory insufficiencies were identified during the investigation. Allegations regarding staffing and service plans were found to be not substantiated after review of tenant files, incident reports, policies, and interviews with staff and administration.
Complaint Details
The complaint involved allegations about staffing levels and service plans. Both allegations were found to be not substantiated based on interviews and documentation review.
Report Facts
Number of tenants without cognitive disorder: 64
Number of tenants with cognitive disorder: 9
Total Population of Program at time of on-site: 73
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Author of the report and contact person for questions |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 4
Mar 24, 2015
Visit Reason
The inspection was conducted as a Final Complaint Investigation and Recertification Monitoring Evaluation following a complaint (#51432-C) and a recertification visit at Legacy Pointe, Iowa City, IA.
Findings
Regulatory insufficiencies were cited related to record checks, tenant documents, service plans, and nurse review. The complaint allegation regarding admission/discharge was unsubstantiated. Deficiencies included failure to complete criminal history background checks prior to employment, incomplete documentation in tenant files, and failure to conduct nurse reviews every 90 days.
Complaint Details
Complaint #51432-C alleged issues with admission/discharge. The allegation was unsubstantiated based on tenant file reviews, program documents, and staff interviews. Regulatory insufficiencies were found in record checks, tenant documents, service plans, and nurse review related to the complaint.
Deficiencies (4)
| Description |
|---|
| Failure to complete a criminal history background check with the Department of Public Safety prior to employment for one staff member. |
| Failure to document by exception in nurses' notes for one tenant file after 9-9-14 despite events requiring documentation. |
| Failure to develop a service plan reflecting identified needs and preferences for one tenant. |
| Failure to complete a nurse review every 90 days for one tenant. |
Report Facts
Number of tenants without cognitive disorder: 56
Number of tenants with cognitive disorder: 6
Total Population of Program at time of on-site: 62
Number of staff files reviewed: 8
Number of tenant files reviewed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant | Named in deficiency for failure to complete criminal history background check prior to employment |
| Staff B | Provided statement regarding tenant #7's condition and care | |
| Kaylan Hamerlinck | Executive Director | Recipient of the report and signed the Plan of Correction |
| Rose Boccella | Program Coordinator, Adult Services Bureau | Author of the cover letter for the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 0
Nov 17, 2014
Visit Reason
The inspection was conducted as a final complaint/incident investigation following a tenant incident involving impaired decision-making and elopement at Silvercrest Legacy Pointe.
Findings
No regulatory insufficiencies were identified. Staff interviews, tenant file review, and observations indicated adequate staffing and adherence to policies. The tenant was safely redirected and monitored, with no injuries or history of prior elopements.
Complaint Details
The complaint involved a tenant with impaired decision-making who left the program without staff knowledge or authorization. The tenant was observed outside the building and redirected inside. Safety checks were initiated and later discontinued at the family's request. There were no prior elopements and no elopements after the incident. Staff followed applicable policies and procedures.
Report Facts
Number of tenants without cognitive disorder: 54
Number of tenants with cognitive disorder: 1
Total population of program at time of on-site: 55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Signed the report and contact person for questions |
Inspection Report
Monitoring
Census: 59
Deficiencies: 2
Apr 9, 2013
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to review the Plan of Correction in response to previously identified regulatory insufficiencies and to evaluate compliance with assisted living program regulations.
Findings
The report found that the program did not receive any regulatory insufficiencies during the certification period. However, some service plans did not reflect tenant identified needs and preferences, and medication administration and documentation protocols were not fully followed.
Deficiencies (2)
| Description |
|---|
| The service plan did not reflect tenant identified needs and preferences for assistance. |
| Medication protocol was not followed regarding administration and documentation of medications. |
Report Facts
Total Population of Program at time of on-site: 59
Number of tenants without cognitive disorder: 52
Number of tenants with cognitive disorder: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | MA | Monitor conducting the evaluation |
| Margaret Kaltefleiter | RN MS | Monitor conducting the evaluation |
| Rose Boccella | Program Coordinator | Author of the cover letter for the report |
Inspection Report
Monitoring
Census: 66
Deficiencies: 0
May 26, 2011
Visit Reason
An on-site monitoring evaluation was conducted at Silvercrest Legacy Pointe to assess compliance with regulatory requirements as part of the final recertification monitoring evaluation.
Findings
No regulatory insufficiencies were found during this onsite recertification monitoring evaluation. The program did not receive any regulatory insufficiencies during the certification period.
Report Facts
Current number of tenants without cognitive disorder: 63
Current number of tenants with cognitive disorder: 3
Total Population: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | MA | Monitor |
| Margaret Kaltefleiter | RN MS | Monitor |
| Joyce Kix | RN | Monitor |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 1
Jun 2, 2009
Visit Reason
A monitoring evaluation and complaint investigation on-site visit were conducted at Silvercrest Legacy Pointe Assisted Living on June 2, 2009, in response to Complaint #22208-C regarding regulatory insufficiency and tenant care concerns.
Findings
The investigation found no regulatory insufficiencies in most areas such as tenant exclusion criteria, food service, staffing, and structural requirements. However, a regulatory insufficiency was noted for failure to notify the Department of Inspections and Appeals within 24 hours of an accident causing substantial injury. The program was assessed a $500 civil penalty, which was paid.
Complaint Details
Complaint #22208-C alleged that a tenant exceeded the appropriate level of care, tenants requested smaller food portions which were not accommodated, administrative staff did not listen to tenant concerns, and a tenant's pendant was not working leading to delayed ambulance response. The complaint was substantiated with a regulatory insufficiency noted for failure to report a tenant's fall with substantial injury.
Deficiencies (1)
| Description |
|---|
| The program did not notify the Department of Inspections and Appeals within twenty-four hours of an accident causing substantial injury or death, or any fire or natural or other disaster occurring at or near the assisted living program. |
Report Facts
Civil penalty amount: 500
Current number of tenants without cognitive disorder: 56
Current number of tenants with cognitive disorder: 1
Total Population: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | MA | Monitor involved in complaint investigation |
| Michael Streepy | RN | Monitor involved in complaint investigation |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed conclusion letter regarding civil penalty and plan of correction |
| Jim Hunter | Executive Director | Facility Executive Director named in report |
Inspection Report
Monitoring
Census: 61
Deficiencies: 4
Apr 6, 2005
Visit Reason
The visit was a re-certification monitoring evaluation conducted to assess compliance with regulatory requirements for the assisted living program at Legacy Pointe.
Findings
The program had several regulatory insufficiencies including failure to evaluate each tenant's functional and cognitive abilities within 30 days of occupancy and annually, failure to update service plans within 30 days, failure to obtain tenant signatures on updated service plans, and lack of appropriately trained direct care staff under the current RN's direction.
Deficiencies (4)
| Description |
|---|
| The program did not evaluate each tenant’s functional and cognitive abilities and health status within 30 days of occupancy and annually. |
| The program did not update the service plan within 30 days of occupancy for tenants receiving personal or health related care. |
| The program did not obtain the tenant’s signature when the service plan was updated within 30 days of admission and annually. |
| The program did not have appropriately trained direct care staff under the direction of the current RN. |
Report Facts
Current number of tenants without cognitive disorder: 54
Current number of tenants with cognitive disorder: 7
Total Population: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Burkhart | Executive Director | Named as Executive Director of the facility and signer of the Plan of Correction letter |
| Stephanie Cummins | SW, MA | Monitor conducting the evaluation |
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