Inspection Reports for
Legacy Rehab & Care Center
2812 Silver Creek Rd, Bullhead City, AZ 86442, United States, AZ, 86442
Back to Facility Profile12 Reports
Inspection Report — Sep 9, 2025
Date: Sep 9, 2025
Visit Reason
The inspection was conducted to assess compliance related to discharge notification procedures, specifically to verify if the facility properly notified the Office of the State Long-Term Care Ombudsman about resident discharges.
Findings
The facility failed to ensure that discharge notifications were made for one of seven residents (#16) to the Ombudsman. Resident #16 left the facility Against Medical Advice (AMA) on November 19, 2023, but was not included in the monthly discharge report sent to the Ombudsman in December 2023, which is against facility policy.
Deficiencies (1)
Failure to provide required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies for Resident #16.
Report Facts
Residents reviewed: 7
Resident discharge date: Nov 19, 2023
Date of inspection: Sep 9, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Staff #21 interviewed regarding discharge notification process and failure to notify Ombudsman | |
| Licensed Practical Nurse | Staff #24 interviewed regarding discharge process and documentation | |
| Director of Nursing | Staff #22 interviewed regarding expectations for discharge notifications |
Inspection Report — Aug 21, 2025
Complaint Investigation
Date: Aug 21, 2025
Visit Reason
On-site complaint investigation of intakes 00136784, 00141512, 00128005, 00125944, 2564746, 2593872, 2257184, and 2256930 at a Nursing Care Institution, conducted 21 August 2025.
Complaint Details
An onsite complaint survey was conducted on August 21, 2025 for the investigation of intake #00136784, 00141512, 00128005, 00125944. Federal comments also note investigation of intake #2564746, 2593872, 2257184, 2256930. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited or citations.
Inspection Report — May 23, 2025
Complaint Investigation
Date: May 23, 2025
Visit Reason
On-site complaint investigation of intakes AZ00224499 and 00130308 at a Nursing Care Institution, conducted 23 May 2025.
Complaint Details
The complaint survey was conducted on May 23, 2025, investigating intake numbers AZ00224499, 00130308, AZ00224487, and AZ224499. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 4
Inspection Report — Apr 15, 2025
Complaint Investigation
Date: Apr 15, 2025
Visit Reason
On-site complaint investigation of intakes 00126417, 00124931, AZ00224000, and AZ00224147 at a Nursing Care Institution, conducted 15 April 2025.
Complaint Details
A complaint survey was conducted on April 15, 2025 for the investigation of intake #00126417, 00124931. There were no deficiencies cited. A complaint survey was conducted on April 15, 2025 for the investigation of intake #AZ00224000, AZ00224147. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Inspection Report — Jan 28, 2025
Date: Jan 28, 2025
Visit Reason
Recertification survey for Medicare under the Life Safety Code 2012, Chapter 19, Existing Health Care Occupancies, conducted 28 January 2025 at a Nursing Care Institution.
Findings
No deficiencies were found during this inspection.
Inspection Report — Jan 17, 2025
Annual Inspection
Date: Jan 17, 2025
Visit Reason
On-site complaint investigation of complaints AZ00219122, AZ00211378, AZ00204532, AZ00201329, AZ00199305, AZ00199004, AZ00197940, AZ00197032, AZ00192173, AZ00198802, AZ00196741, AZ00185029, AZ001850125, AZ00184873, conducted in conjunction with the annual compliance survey at a Nursing Care Institution from 14 to 17 January 2025.
Complaint Details
The state compliance survey was conducted on January 14, 2025 through January 17, 2025, in conjunction with the investigation of complaints #AZ00219122, AZ00211378, AZ00204532, AZ00201329, AZ00199305, AZ00199004, AZ00197940, AZ00197032, AZ00192173, AZ00198802, AZ00196741, AZ00185029, AZ001850125, AZ00184873. The recertification survey was conducted on January 14, 2025 through January 17, 2025, in conjunction with the investigation of complaints #AZ00219120, AZ00211377, AZ00204529, AZ00201328, AZ00199304, AZ00199001, AZ00197939, AZ00197031, AZ00192174, AZ00198802, AZ00196741, AZ00185029, AZ001850125, AZ00184873. There were no deficiencies cited.
Findings
This inspection found no deficiencies.
Inspection Report — Aug 29, 2024
Complaint Investigation
Date: Aug 29, 2024
Visit Reason
On-site complaint investigation of intakes AZ00214899, AZ00213621, and AZ00214898 at a Nursing Care Institution, conducted 29 August 2024.
Complaint Details
An onsite complaint survey was conducted on August 29, 2024 for the investigation of intake # AZ00214899, AZ00213621, and AZ00214898. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 3
Inspection Report — Mar 5, 2024
Complaint Investigation
Date: Mar 5, 2024
Visit Reason
On-site complaint investigation of intakes AZ00206968 and AZ00207077 at a Nursing Care Institution, conducted 5 March 2024.
Complaint Details
An onsite complaint survey was conducted on March 5, 2024 for the investigation of intake #s AZ00206968, AZ00207077. There were no deficiencies cited. Federal comments also note investigation of intake #s AZ00206968, AZ00207074 with no deficiencies cited.
Findings
No deficiencies were cited during this inspection.
Inspection Report — Aug 23, 2023
Complaint Investigation
Date: Aug 23, 2023
Visit Reason
On-site complaint investigation of complaint AZ00199225 at a Nursing Care Institution, conducted 23 August 2023.
Complaint Details
An onsite survey was conducted on August 23, 2023 for the investigation of AZ00199225. The complaint survey was conducted on August 23, 2023 for the investigation of AZ00199224. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Feb 9, 2023
Routine
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 — Dec 2, 2021
Complaint Investigation
Date: Dec 2, 2021
Visit Reason
The inspection was conducted due to complaints regarding failure to provide timely notification of resident transfers, failure to administer medications as ordered, and failure to maintain infection prevention and control during meal tray delivery.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure to notify resident and representative in writing of transfer, failure to send notice to Ombudsman, failure to administer medications as ordered, and failure to maintain infection prevention and control during meal delivery.
Findings
The facility failed to notify a resident and their representative in writing of a transfer and failed to send a copy of the notice to the Ombudsman. The facility also failed to ensure medications were administered as ordered for one resident, with missing documentation on the Medication Administration Record. Additionally, the facility failed to maintain proper infection prevention and control practices during meal tray delivery, including failure of staff to perform hand hygiene between residents.
Deficiencies (3)
Failure to provide timely written notification to resident and representative of transfer and failure to send notice to Ombudsman.
Failure to ensure medications were administered as ordered for one resident, with missing documentation on medication administration record.
Failure to maintain infection prevention and control during meal tray delivery, including failure to perform hand hygiene.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 10
Sample size: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Interviewed regarding transfer/discharge notification process and failure to send notice to Ombudsman | |
| Director of Nursing | Interviewed regarding expectations for transfer notification and medication administration documentation | |
| Administrator | Interviewed regarding awareness of transfer notification requirements and Ombudsman notification | |
| Certified Medication Aide | Interviewed regarding medication administration practices | |
| Licensed Practical Nurse | Interviewed regarding medication administration and documentation | |
| Dietary Server | Interviewed regarding hand hygiene practices during meal tray delivery | |
| Corporate Infection Control and Minimum Data Set Nurse | Interviewed regarding hand hygiene expectations and infection control |
Inspection Report — Dec 2, 2021
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
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 |
4 CMS Surveys
CMS Survey — Sep 9, 2025
Sep 9, 2025
CMS Survey — Dec 2, 2021
Dec 2, 2021
CMS Survey — Feb 9, 2023
Feb 9, 2023
CMS Survey — Jan 17, 2025
Jan 17, 2025
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