Inspection Reports for
Legacy Rehab & Care Center
2812 Silver Creek Rd, Bullhead City, AZ 86442, United States, AZ, 86442
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
19% better than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Deficiencies: 1
Date: Sep 9, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to discharge notifications to the Office of the State Long-Term Care Ombudsman.
Findings
The facility failed to ensure that discharge notifications were made for one of seven residents (#16) to the Ombudsman, specifically omitting Resident #16 from the December 2023 discharge report despite the resident leaving Against Medical Advice (AMA) on November 19, 2023.
Deficiencies (1)
Failure to provide required discharge notification to the Office of the State Long-Term Care Ombudsman for Resident #16.
Report Facts
Residents reviewed: 7
Resident discharge date: Nov 19, 2023
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #21 | Social Services Director | Provided information on discharge notification process and confirmed omission of Resident #16 from Ombudsman report |
| Staff #24 | Licensed Practical Nurse | Described role in discharge process and documentation for AMA discharges |
| Staff #22 | Director of Nursing | Stated expectations for discharge notifications and confirmed failure to notify Ombudsman for Resident #16 |
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 0
Date: Aug 21, 2025
Visit Reason
An onsite complaint survey was conducted for multiple intake investigations with no deficiencies cited.
Findings
An onsite complaint survey was conducted for multiple intake investigations with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 0
Date: May 23, 2025
Visit Reason
Complaint survey conducted with no deficiencies cited.
Findings
Complaint survey conducted with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 0
Date: Apr 15, 2025
Visit Reason
Complaint survey conducted with no deficiencies cited.
Findings
Complaint survey conducted with no deficiencies cited.
Inspection Report
Capacity: 120
Deficiencies: 0
Date: Jan 28, 2025
Visit Reason
Recertification survey for Medicare under Life Safety Code 2012 with no deficiencies found.
Findings
Recertification survey for Medicare under Life Safety Code 2012 with no deficiencies found.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 17, 2025
Visit Reason
The inspection was conducted as an annual survey of The Legacy Rehab & Care Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 0
Date: Jan 14, 2025
Visit Reason
State compliance survey conducted with multiple complaint investigations; no deficiencies cited.
Findings
State compliance survey conducted with multiple complaint investigations; no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 0
Date: Aug 29, 2024
Visit Reason
Onsite complaint survey conducted with no deficiencies cited.
Findings
Onsite complaint survey conducted with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 0
Date: Mar 5, 2024
Visit Reason
Onsite complaint survey conducted with no deficiencies cited.
Findings
Onsite complaint survey conducted with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 0
Date: Aug 23, 2023
Visit Reason
Onsite complaint survey conducted with no deficiencies cited.
Findings
Onsite complaint survey conducted with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 4
Date: Feb 9, 2023
Visit Reason
State compliance survey with multiple complaint investigations; four deficiencies cited related to pre-admission screening, environmental conditions, and premises safety.
Findings
State compliance survey with multiple complaint investigations; four deficiencies cited related to pre-admission screening, environmental conditions, and premises safety.
Deficiencies (4)
R9-10-403.C — Administrator policies and procedures for physical and behavioral health services
§483.20(k) — Preadmission Screening for individuals with mental disorder and intellectual disability
§483.90(i) — Other Environmental Conditions
R9-10-425.A — Nursing care institution premises and equipment safety
Inspection Report
Capacity: 120
Deficiencies: 2
Date: Feb 9, 2023
Visit Reason
Life Safety Code survey citing two deficiencies related to fire alarm system testing and fire drills.
Findings
Life Safety Code survey citing two deficiencies related to fire alarm system testing and fire drills.
Deficiencies (2)
Fire Alarm - Out of Service — Failure to test fire alarm system monthly
Fire Drills — Incomplete fire drill procedures
Inspection Report
Routine
Deficiencies: 2
Date: Feb 9, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including Pre-admission Screening and Resident Review (PASARR) for mental disorders or intellectual disabilities, and to ensure safe water temperatures in resident rooms.
Findings
The facility failed to complete a required PASARR Level II assessment for one resident, despite documentation indicating the need for it. Additionally, water temperatures in multiple resident rooms were found to be above the safe range, posing a risk of burns.
Deficiencies (2)
Failure to ensure that a required Pre-admission Screening and Resident Review Level II was completed for one resident (#3).
Failure to maintain hot water temperatures within the safe range in resident rooms, with temperatures exceeding federal guidelines.
Report Facts
Water temperature: 130.6
Water temperature: 131.4
Water temperature: 126
Water temperature: 127.5
Water temperature: 131.9
Water temperature: 131.6
Water temperature: 130.6
Water temperature: 130.2
Water temperature: 131.1
Water temperature: 128.8
Water temperature: 130
Water temperature: 128
Water temperature: 114.1
Water temperature: 112.4
Water temperature: 111.5
Water temperature: 109
Water temperature: 111
Water temperature: 110
Water temperature: 105
Water temperature: 109
Water temperature: 105.5
Water temperature: 106
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Admissions Coordinator | Admissions Coordinator (staff #89) | Stated that initial PASARR Level 1 is done on admission and further reviews by Social Worker |
| Medical Records Coordinator | Medical Records Coordinator (staff #12) | Stated no Level II PASARR documentation found in resident's chart |
| Certified Nursing Assistant | Certified Nursing Assistant (staff #44) | Covered for Social Worker and unable to locate Level II assessment documentation |
| Director of Nursing | Director of Nursing (staff #45) | Stated Pre-admission Screening and Resident Reviews handled by admissions and Social Worker |
| Administrator | Administrator (staff #101) | Notified of high water temperatures on February 6, 2023 |
| Maintenance Manager | Maintenance Manager (staff #32) | Unaware of high water temperatures and stated he would correct them immediately |
Inspection Report
Census: 46
Deficiencies: 3
Date: Dec 2, 2021
Visit Reason
The inspection was conducted to evaluate compliance with federal regulations regarding resident transfer notifications, medication administration, and infection prevention and control practices at The Legacy Rehab & Care Center.
Findings
The facility failed to provide timely written notification to a resident and their representative regarding a hospital transfer and failed to send a copy of the notice to the Ombudsman. Medication administration documentation was incomplete for one resident, with missing records for several medications on specific dates. Infection prevention practices were deficient as staff delivering meal trays did not perform hand hygiene between residents, increasing risk of infection transmission.
Deficiencies (3)
Failed to notify one resident and the resident's representative in writing of a transfer and failed to send a copy of the notice to the Office of the State Long Term Care Ombudsman.
Failed to ensure medications were administered as ordered for one resident; medication administration records were incomplete with no documentation explaining missed doses.
Failed to maintain infection prevention and control when delivering meal trays; staff did not perform hand hygiene before, during, or after serving meals to residents.
Report Facts
Residents affected: 1
Residents affected: 1
Census: 46
Sample size: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director (SSD) | Interviewed regarding transfer/discharge notice procedures and failure to send notice to Ombudsman |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations for transfer notification and medication administration documentation |
| Administrator | Administrator | Interviewed regarding awareness of transfer notification requirements and Ombudsman notification |
| Certified Medication Aide | Certified Medication Aide (CMA) | Interviewed regarding medication administration practices and documentation |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration and documentation practices |
| Dietary Server | Dietary Server | Interviewed regarding hand hygiene practices during meal tray delivery |
| Corporate Infection Control and Minimum Data Set Nurse | Corporate Infection Control and Minimum Data Set Nurse | Interviewed regarding hand hygiene expectations and infection prevention |
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