Inspection Reports for Legacy Rehab & Care Center
2812 Silver Creek Rd, Bullhead City, AZ 86442, United States, AZ, 86442
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Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 6
Aug 21, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2023-02 to 2025-08 with deficiency history and complaint investigations.
Findings
Across all inspections, the facility had multiple complaint and compliance surveys with most inspections citing no deficiencies. The February 2023 inspections identified four deficiencies related to pre-admission screening and resident review, environmental conditions regarding hot water temperatures, and two deficiencies related to life safety code violations involving fire alarm testing and fire drills.
Complaint Details
Multiple complaint investigations were conducted including intake numbers 00136784, 00141512, 00128005, 00125944, AZ00224499, 00130308, 00126417, 00124931, AZ00219122, AZ00211378, AZ00204532, AZ00201329, AZ00199305, AZ00199004, AZ00197940, AZ00197032, AZ00192173, AZ00198802, AZ00196741, AZ00185029, AZ001850125, AZ00184873, AZ00214899, AZ00213621, AZ00206968, AZ00207077, AZ00199225, and others as listed in inspections.
Deficiencies (6)
| Description |
|---|
| R9-10-403.C. An administrator shall ensure that: Policies and procedures for physical health services and behavioral health services are established, documented, and implemented to protect the health and safety of a resident that include resident screening and discharge planning. Failed to ensure a required Pre-Admission Screening and Resident Review Level II was completed for one resident. |
| §483.20(k) Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability. Failed to ensure that a required Pre-Admission Screening and Resident Review Level II was completed for one resident. |
| §483.90(i) Other Environmental Conditions. The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. Failed to ensure hot water temperatures remained in the safe range in resident rooms, with temperatures exceeding 130 degrees F in multiple rooms. |
| R9-10-425.A. An administrator shall ensure that a nursing care institution's premises and equipment are free from a condition or situation that may cause a resident or an individual to suffer physical injury. Failed to maintain safe water temperatures, exposing residents to risk of burns. |
| Fire Alarm - Out of Service. Where required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch provided. Failed to test the fire alarm system monthly as required. |
| Fire Drills. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. Failed to fully complete all aspects of a fire drill including emergency phone call to the fire department and documentation of the required phone call. |
Report Facts
Inspections on page: 10
Total deficiencies: 6
Complaint inspections: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator (staff #101) | Administrator | Notified of water temperature issues and acknowledged fire alarm and fire drill deficiencies |
| Director of Nursing (staff #45) | Director of Nursing | Interviewed regarding Pre-Admission Screening and Resident Reviews |
| Admissions Coordinator (staff #89) | Certified Nursing Assistant | Interviewed about PASARR Level 1 and Level II assessments |
| Medical Records Coordinator (staff #12) | Medical Records Coordinator | Interviewed about missing Pre-Admission Screening and Resident Reviews |
| Certified Nursing Assistant (staff #44) | Certified Nursing Assistant | Interviewed about missing Level II assessment documentation |
| Maintenance Manager (staff #32) | Maintenance Manager | Interviewed about water temperature issues and fire alarm system maintenance |
| Director of Maintenance | Director of Maintenance | Acknowledged fire alarm and fire drill deficiencies |
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