Inspection Reports for Legacy Transitional Care & Rehabilitation
460 AUBURN AVENUE N.E., ATLANTA, GA, 30312
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 4, 2025, found no deficiencies, with all prior issues from April 2025 corrected and complaint investigations unsubstantiated. Earlier inspections showed recurring deficiencies primarily related to infection control, environmental cleanliness, medication management, and safety concerns including fire safety and call light system functionality. Complaint investigations were mostly unsubstantiated, though some substantiated complaints did not result in deficiencies. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows improvement over time, with recent surveys confirming correction of previously cited deficiencies.
Deficiencies (last 10 years)
Deficiencies (over 10 years)
19.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
292% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
179 residents
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Nov 17, 2025
Visit Reason
The inspection was conducted to assess compliance with facility maintenance and resident safety standards, including the condition of resident rooms and the functionality of the call light communication system.
Findings
The facility failed to maintain three of 14 shared bedrooms on the 400 hall in good repair, with issues such as chipped and peeling paint, scuffed sheetrock, damaged or broken electrical outlets, and inoperable overbed lights. Additionally, the call light communication system was not functioning adequately in two restrooms on the 200 hall and two rooms on the 300 hall, with call lights hanging from walls, exposed wires, and detached emergency call devices.
Deficiencies (2)
Failed to maintain three of 14 shared bedrooms on the 400 hall in good repair, including chipped and peeling paint, scuffed sheetrock, damaged or broken electrical outlets, and inoperable overbed lights.
Failed to ensure the call light communication system was functioning adequately in two restrooms on the 200 hall and two rooms on the 300 hall, with call lights hanging off walls, exposed wires, and detached emergency call devices.
Report Facts
Shared bedrooms with deficiencies: 3
Restrooms with non-functioning call lights: 2
Rooms with non-functioning call lights: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Confirmed damaged walls, broken outlets, inoperable overbed lights, and non-functioning call light devices during interviews and walking rounds. | |
| Administrator | Acknowledged awareness of environmental concerns and stated assignment of three Maintenance Personnel to designated floors with additional tools for daily checks. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Nov 17, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory standards related to facility maintenance, resident care, and safety systems.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, including damaged walls, broken electrical outlets, and inoperable overbed lights in resident rooms. Additionally, the facility failed to submit a required PASARR Level II screening for one resident with schizophrenia, and the call light communication system was not functioning properly in multiple resident bathrooms and rooms.
Deficiencies (3)
Failed to maintain three of 14 shared bedrooms on the 400 hall in good repair, including chipped and peeling paint, scuffed sheetrock, damaged or broken electrical outlets, and inoperable overbed lights.
Failed to ensure PASARR Level II screening was submitted for one of five residents (R8) with mental disorders or intellectual disabilities, potentially preventing attainment of highest practicable mental and psychosocial well-being.
Failed to ensure the call light communication system was functioning adequately in two out of seven restrooms on the 200 hall and two of 14 rooms (301, 305) on the 300 hall, with call lights hanging off walls, wires exposed, and emergency call devices detached.
Report Facts
Shared bedrooms with maintenance issues: 3
Residents without PASARR Level II submission: 1
Restrooms with non-functioning call lights: 2
Rooms with non-functioning call lights: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Social Worker | Confirmed resident R8 did not have a PASARR Level II submission. |
| Maintenance Director | Confirmed damaged walls, broken outlets, inoperable lights, and non-functioning call light devices. | |
| Administrator | Acknowledged environmental concerns and staffing for maintenance rounds. | |
| Social Service Director | Revealed resident R8 had no PASARR Level II application submitted. | |
| MDS Director | Revealed diagnosis is checked but PASARR status is not checked upon admission. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 4, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Legacy Transitional Care & Rehabilitation following a survey completed on June 4, 2025.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 4, 2025
Visit Reason
A revisit survey was conducted at Legacy Transitional Care & Rehabilitation from June 3, 2025, through June 4, 2025, including investigation of Complaint Intake Number GA00254999.
Complaint Details
Complaint Intake Number GA00254999 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
All deficiencies cited during the April 11, 2025 recertification survey were found to be corrected. The complaint investigation was unsubstantiated with no deficiencies cited.
Report Facts
Complaint Intake Number: 254999
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 4, 2025
Visit Reason
A revisit survey was conducted at Legacy Transitional Care & Rehabilitation from June 3 through June 4, 2025, including an investigation of Complaint Intake Number GA00254999.
Complaint Details
Complaint Intake Number GA00254999 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
All deficiencies cited during the April 11, 2025 recertification survey were found to be corrected. The complaint investigation was unsubstantiated with no deficiencies cited.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 22, 2025
Visit Reason
A follow-up survey was conducted to verify correction of previously cited survey deficiencies.
Findings
The follow-up survey noted that all previously cited survey tags had been corrected.
Inspection Report
Abbreviated Survey
Census: 179
Deficiencies: 0
Date: May 19, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00255055 at Legacy Transitional Care and Rehabilitation.
Complaint Details
Complaint GA00255055 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint GA00255055 was unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Life Safety
Census: 165
Capacity: 186
Deficiencies: 3
Date: Apr 17, 2025
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, including missing ceiling tiles in the second floor soiled linen room, improperly maintained smoke barrier doors that did not close properly, and unsecured oxygen bottles stored in a non-designated closet.
Deficiencies (3)
Missing ceiling tile in soiled linen room on second floor.
Smoke door was not closing properly for a correct seal in one smoke compartment.
Oxygen bottles were not properly secured and were located in a non-designated area closet.
Report Facts
Census: 165
Total Capacity: 186
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Interviewed and confirmed findings during facility tour |
Inspection Report
Annual Inspection
Capacity: 64
Deficiencies: 4
Date: Apr 11, 2025
Visit Reason
A State Licensure survey was conducted at Legacy Transitional Care & Rehabilitation from April 8, 2025 through April 11, 2025 to assess compliance with state health and safety regulations.
Findings
The facility was found deficient in multiple areas including failure to maintain a Water Management Program, improper infection control practices related to linen storage and gastrostomy tube care, unsanitary laundry and housekeeping conditions, failure to follow comprehensive person-centered care plans, unclean PTAC units in resident rooms, and improper labeling and sanitation of food items and ice machine in the kitchen.
Deficiencies (4)
Failure to maintain a Water Management Program and improper infection control related to linen storage and gastrostomy tube care for one resident.
Failure to follow comprehensive person-centered care plan for one of 64 sampled residents.
Failure to maintain clean Packaged Terminal Air Conditioner (PTAC) units in seven resident rooms.
Failure to ensure food items in the freezer were labeled and dated and failure to maintain sanitary conditions of the ice machine.
Report Facts
Number of sampled residents: 64
Number of resident rooms with unclean PTAC units: 7
Expiration date on expired food item: Dec 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN DD | Licensed Practical Nurse, Charge Nurse | Responsible for tube feedings on unit; admitted to sometimes cleaning G-tube sites |
| LPN AA | Unit Manager | Confirmed G-tube site care was not performed as ordered |
| Maintenance Director | Confirmed no Water Management Program; responsible for laundry room cleanliness and ice machine cleaning | |
| Housekeeping Director | Observed laundry and PTAC unit deficiencies; responsible for ensuring PTAC units are clean | |
| Administrator | Acknowledged lack of Water Management Program and infection control risks | |
| Dietary Manager | Confirmed unsanitary ice machine and food labeling deficiencies | |
| Head Cook | Provided information on food labeling and expiration protocols | |
| MDS LL | Unaware of communication device needed for resident R36 | |
| Director of Nursing | Stated care plans must be followed if indicated | |
| Laundry Aide QQ | Noticed washing machine leak and informed Housekeeping Director |
Inspection Report
Annual Inspection
Census: 182
Deficiencies: 8
Date: Apr 11, 2025
Visit Reason
A recertification survey was conducted from April 8 to April 11, 2025, including investigation of multiple complaint intake numbers, to assess compliance with Medicare/Medicaid regulations for Legacy Transitional Care & Rehabilitation.
Complaint Details
The survey included investigation of Complaint Intake Numbers GA00253884, GA00254333, GA00254456, and GA00254525 in conjunction with the standard survey.
Findings
The survey revealed multiple deficiencies including failure to provide language assistance to a resident with limited English proficiency, failure to maintain clean environmental surfaces such as PTAC units, failure to document significant change assessments and discharge status accurately, failure to follow comprehensive person-centered care plans, failure to follow physician orders for gastrostomy tube care, failure to maintain sanitary kitchen conditions including ice machine and food labeling, failure to maintain a water management program, improper storage of clean linens, and failure to maintain a clean laundry area.
Deficiencies (8)
Failure to provide language assistance resources to a resident with limited English proficiency.
Failure to maintain clean Packaged Terminal Air Conditioner (PTAC) units in seven rooms, increasing infection risk.
Failure to document significant change assessment upon readmittance and change to hospice status for one resident and inaccurate discharge status documentation for another.
Failure to follow comprehensive person-centered care plan for a resident with communication barriers.
Failure to follow physician's orders to check residual and gastrostomy tube placement for one resident receiving tube feedings.
Failure to ensure food items in the freezer were labeled and dated and failure to maintain sanitary conditions of the ice machine in the kitchen.
Failure to maintain a Water Management Program, improper storage of clean linen rack uncovered and unsupervised, and failure to maintain a clean and sanitary laundry area.
Failure to disinfect a gastrostomy tube site per physician orders for one resident.
Report Facts
Residents present: 182
Rooms with unclean PTAC units: 7
Residents sampled: 64
Residents receiving tube feedings: 10
Expiration date on unlabeled food item: Dec 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN DD | Charge Nurse - Licensed Practical Nurse | Named in failure to check gastrostomy tube placement and residuals during medication administration |
| LPN AA | Unit Manager - Licensed Practical Nurse | Named in failure to cleanse gastrostomy tube site |
| MDS Coordinator OO | MDS Coordinator | Named in failure to accurately document discharge status |
| MDS Manager LL | MDS Manager | Named in failure to document hospice status on MDS |
| Housekeeping Director | Named in failure to maintain clean laundry and linen storage | |
| Maintenance Director | Named in failure to maintain ice machine and water management program | |
| Dietary Manager | Named in failure to maintain sanitary kitchen conditions | |
| Administrator | Named in oversight of water management and linen storage |
Inspection Report
Routine
Deficiencies: 8
Date: Apr 11, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, environmental safety, infection control, and food safety at Legacy Transitional Care & Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to provide language assistance to a non-English speaking resident, inadequate cleaning of PTAC units, inaccurate resident assessments, incomplete care plans, improper gastrostomy tube care and feeding tube management, unsanitary kitchen and laundry conditions, and lack of a water management program.
Deficiencies (8)
Failure to ensure a resident with limited English proficiency was provided with resources to access and understand healthcare communications.
Failure to maintain clean Packaged Terminal Air Conditioner (PTAC) units in resident rooms, increasing risk of infections.
Failure to document a significant change assessment upon re-admittance and change to hospice status for one resident and inaccurate discharge status documentation for another.
Failure to follow a comprehensive person-centered care plan for a resident with communication barriers.
Failure to follow physician's orders to check residual and gastrostomy tube placement for a resident receiving tube feedings.
Failure to maintain sanitary conditions of the gastrostomy tube site, including presence of crusty material and unsecured tape.
Failure to ensure food items in the freezer were labeled and dated and failure to discard expired food; unsanitary conditions of the ice machine.
Failure to maintain a Water Management Program, improper storage of clean linen, unsanitary laundry conditions including debris and leaks, and failure to disinfect gastrostomy tube site per physician orders.
Report Facts
Residents affected: 1
Rooms with soiled PTAC units: 7
Residents sampled: 64
Residents receiving tube feedings: 10
Expiration date of beef stew: Dec 24, 2024
MDS BIMS score: 0
Tube feeding rate: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DD | Charge Nurse Licensed Practical Nurse (LPN) | Named in gastrostomy tube feeding and site care deficiencies |
| LL | MDS Manager | Interviewed regarding resident assessments and care plans |
| OO | MDS Coordinator | Interviewed regarding resident assessments and care plans |
| AA | LPN Unit Manager | Observed gastrostomy tube site condition |
| RR | Certified Nurse Assistant (CNA) | Interviewed about language assistance availability |
| SS | Certified Nurse Assistant (CNA) | Interviewed about language assistance availability |
| TT | Licensed Practical Nurse (LPN) | Interviewed about language assistance availability |
| UU | Social Worker (SW) | Interviewed about language assistance and communication devices |
| DON | Director of Nursing | Interviewed about language assistance, care plan adherence, and staff education |
| DM | Dietary Manager | Interviewed about ice machine sanitation and food labeling |
| HD | Housekeeping Director | Interviewed about PTAC unit cleaning and laundry sanitation |
| MD | Maintenance Director | Interviewed about PTAC unit cleaning, ice machine maintenance, and water management |
| CC | Licensed Practical Nurse (LPN) | Interviewed about gastrostomy tube feeding procedures |
| Laundry Aide | Interviewed about laundry room cleaning | |
| Administrator | Facility Administrator | Interviewed about communication, care quality, and facility cleanliness |
| Human Resource Manager | Interviewed about staff skills check-offs |
Inspection Report
Routine
Deficiencies: 8
Date: Apr 11, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, care planning, infection control, environmental cleanliness, and food safety at Legacy Transitional Care & Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to provide language assistance to a non-English speaking resident, unclean PTAC units in resident rooms, inaccurate resident assessments, incomplete care plans, improper feeding tube care, unsanitary kitchen and laundry conditions, and lack of a water management program. These deficiencies posed risks of communication barriers, infection, inaccurate care documentation, and compromised resident safety.
Deficiencies (8)
Failure to ensure a resident with limited English proficiency was provided with resources to access and understand healthcare communications.
Failure to maintain clean Packaged Terminal Air Conditioner (PTAC) units in seven resident rooms, increasing risk of infections.
Failure to document a significant change assessment upon re-admittance and change to hospice status for one resident and inaccurate discharge status documentation for another.
Failure to follow a comprehensive person-centered care plan for a resident with communication barriers.
Failure to follow physician's orders to check residual and gastrostomy tube placement for one resident receiving tube feedings.
Failure to maintain sanitary conditions of the gastrostomy tube site for one resident, with crusty material and unsecured tube tape observed.
Failure to ensure food items in the freezer were labeled and discarded by expiration date and failure to maintain sanitary conditions of the ice machine in the kitchen.
Failure to maintain a Water Management Program, failure to prevent infection spread by improper storage of clean linen, unsanitary laundry conditions, and failure to disinfect gastrostomy tube site per physician orders.
Report Facts
Rooms with unclean PTAC units: 7
Residents sampled: 64
Residents receiving tube feedings: 10
Expiration date on frozen food: Dec 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DD | Charge Nurse Licensed Practical Nurse (LPN) | Named in feeding tube residual and placement check deficiency and gastrostomy site care |
| LL | MDS Manager | Named in resident assessment and care plan documentation deficiency |
| OO | MDS Coordinator | Named in resident assessment and care plan documentation deficiency |
| AA | Licensed Practical Nurse (LPN) Unit Manager | Named in gastrostomy site care deficiency |
| CC | Licensed Practical Nurse (LPN) | Named in feeding tube placement and residual check deficiency |
| RR | Certified Nurse Assistant (CNA) | Named in language assistance deficiency |
| SS | Certified Nurse Assistant (CNA) | Named in language assistance deficiency |
| TT | Licensed Practical Nurse (LPN) | Named in language assistance deficiency |
| UU | Social Worker (SW) | Named in language assistance deficiency |
| HD | Housekeeping Director | Named in PTAC cleaning and laundry sanitation deficiencies |
| MD | Maintenance Director | Named in PTAC cleaning, ice machine sanitation, water management, and laundry sanitation deficiencies |
| DM | Dietary Manager | Named in kitchen sanitation and food labeling deficiencies |
| Administrator | Facility Administrator | Named in resident assessment, care planning, and environmental sanitation deficiencies |
Inspection Report
Abbreviated Survey
Census: 184
Deficiencies: 0
Date: Feb 6, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00252845, GA00252949, GA00253330, and GA00253558.
Complaint Details
Complaints GA00252845, GA00252949, GA00253330, and GA00253558 were investigated and found to be unsubstantiated.
Findings
The complaints investigated were unsubstantiated, and no regulatory violations were cited during the survey.
Inspection Report
Deficiencies: 0
Date: Jan 3, 2025
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Legacy Transitional Care & Rehabilitation, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details or findings of deficiencies.
Inspection Report
Re-Inspection
Census: 177
Deficiencies: 0
Date: Jan 3, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the prior recertification with complaint survey conducted on 2024-11-08.
Complaint Details
The revisit survey was related to a prior complaint survey conducted on 11/8/2024.
Findings
All deficiencies cited as a result of the 11/8/2024 recertification with complaint survey were found to be corrected.
Report Facts
Census: 177
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 18, 2024
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Renewal
Census: 181
Deficiencies: 9
Date: Nov 8, 2024
Visit Reason
A standard Recertification survey was conducted from November 5 through November 8, 2024, including investigation of a complaint intake number GA00251918, which was substantiated without deficiencies.
Complaint Details
Complaint Intake Number GA00251918 was investigated in conjunction with the standard survey and was substantiated without deficiencies.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations with multiple deficiencies including failure to assess resident self-medication, failure to provide required Medicare notices, environmental cleanliness issues, incomplete employee background checks, failure to refer for PASRR Level II, inadequate nail care for residents, improper food handling and labeling, unsanitary dumpster area, and failure to clean reusable medical equipment between uses.
Deficiencies (9)
Failure to ensure one resident was assessed to safely self-administer medications, with medication left unattended at bedside.
Failure to appropriately provide Notice of Medicare Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice to one resident.
Failure to maintain a safe, clean, comfortable, homelike environment in two resident rooms, including dirty fan blades and damaged bathroom ceiling.
Failure to obtain fingerprint and reference checks for multiple employee files reviewed.
Failure to refer a resident with serious mental illness for Level II PASRR evaluation.
Failure to provide nail care for two residents, with observations of overgrown and dirty nails.
Failure to discard food items by expiration or use-by date, presence of moldy food, and failure to ensure dietary staff wore beard coverings.
Failure to maintain dumpster area in sanitary condition with discarded items on the ground.
Failure to clean reusable medical equipment between resident uses, risking spread of infection.
Report Facts
Residents sampled: 60
Facility census: 181
Employee files reviewed: 10
Residents with nail care deficiency: 2
Rooms with environmental deficiencies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Named in medication administration and self-medication assessment deficiency |
| CMAT GGG | Certified Medication Aide | Named in medication administration deficiency |
| Director of Nursing (DON) | Director of Nursing | Named in medication administration, infection prevention, and nail care deficiencies |
| Social Services Director (SSD) | Social Services Director | Named in Medicare notice and PASRR referral deficiencies |
| Assistant Nursing Home Administrator | Named in employee file background check deficiency | |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Named in employee file background check deficiency |
| Certified Nursing Assistant (CNA) AA | Certified Nursing Assistant | Named in nail care deficiency |
| LPN CC | Licensed Practical Nurse | Named in nail care deficiency |
| Dietary Manager (DM) NN | Dietary Manager | Named in food handling and labeling deficiency |
| Maintenance Director (MD) | Maintenance Director | Named in environmental maintenance deficiency |
| Kitchen Aid (KA) CCC | Kitchen Aid | Named in food handling and hygiene deficiency |
| Certified Medication Aid (CMA) DD | Certified Medication Aide | Named in reusable medical equipment cleaning deficiency |
| Certified Medication Aid (CMA) EE | Certified Medication Aide | Named in reusable medical equipment cleaning deficiency |
Inspection Report
Routine
Census: 181
Deficiencies: 6
Date: Nov 8, 2024
Visit Reason
A State Licensure survey was conducted at Legacy Transitional Care and Rehabilitation from November 5, 2024, through November 8, 2024, to assess compliance with state health regulations.
Findings
The survey identified multiple deficiencies including failure to provide proper Medicare non-coverage notices, inadequate infection control practices, failure to provide nail care to residents, environmental sanitation issues, improper food handling, and incomplete employee background screening documentation.
Deficiencies (6)
Failure to appropriately provide Notice of Medicare Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice to a resident.
Failure to ensure reusable medical equipment was cleaned between use for residents, risking spread of infection.
Failure to provide nail care for two residents as required by their care plans.
Failure to maintain a safe, clean, comfortable, homelike environment in two rooms, including dirty fan blades and damaged bathroom ceiling with black stains.
Failure to discard food items by expiration or use-by date, presence of moldy food, and failure to ensure dietary staff wore beard coverings.
Failure to obtain fingerprint checks for four employees and reference checks for two employees in personnel files.
Report Facts
Facility census: 181
Sampled residents: 60
Residents with nail care deficiency: 2
Employee files reviewed: 10
Employees missing fingerprint checks: 4
Employees missing reference checks: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aid DD | Certified Medication Aid | Observed not cleaning blood pressure equipment between residents |
| Certified Medication Aid EE | Certified Medication Aid | Observed not cleaning blood pressure equipment between residents |
| Social Services Director | Social Services Director | Responsible for providing Medicare non-coverage notices; confirmed missing resident signatures |
| Licensed Practical Nurse CC | Licensed Practical Nurse | Confirmed resident's fingernails were dirty and jagged |
| Certified Nursing Assistant AA | Certified Nursing Assistant | Described nail care and bathing procedures |
| Licensed Practical Nurse BB | Licensed Practical Nurse | Confirmed lack of podiatry visits and shower sheet documentation |
| Director of Nursing | Director of Nursing | Confirmed infection prevention policies and nail care expectations |
| Dietary Manager | Dietary Manager | Confirmed lack of food dating and labeling knowledge |
| Administrator | Administrator | Confirmed environmental and dietary deficiencies and missing employee background checks |
Inspection Report
Annual Inspection
Census: 181
Deficiencies: 9
Date: Nov 8, 2024
Visit Reason
The inspection was conducted as part of the annual survey of Legacy Transitional Care & Rehabilitation to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to assess residents for safe self-administration of medications, failure to provide required notices related to Medicare coverage, failure to maintain a safe and clean environment, incomplete employee background checks, failure to refer residents for appropriate mental health screening, inadequate provision of activities of daily living such as nail care, improper food handling and storage, unsanitary dumpster area, and failure to clean reusable medical equipment between residents.
Deficiencies (9)
Failed to ensure one resident was assessed to safely self-administer medications, risking access to medications not prescribed to them.
Failed to appropriately provide Notice of Medicare Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice to one resident.
Failed to maintain a safe, clean, comfortable, homelike environment in two rooms, including dirty circulating fan and damaged bathroom ceiling with black stains.
Failed to obtain fingerprint and reference checks for multiple employee files.
Failed to refer a resident with serious mental illness for Level II PASRR evaluation and determination of specialized services.
Failed to provide nail care for two residents as part of activities of daily living.
Failed to discard food items by expiration or use-by date, failed to discard food with mold, and failed to ensure dietary staff wore beard coverings.
Failed to maintain dumpster area in sanitary condition, with discarded items on the ground.
Failed to ensure reusable medical equipment was cleaned between use for residents, risking spread of infection.
Report Facts
Residents sampled: 60
Facility census: 181
Employee files reviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Licensed Practical Nurse (LPN) | Named in medication administration and self-medication assessment deficiency |
| GGG | Certified Medication Aide (CMA) | Named in medication administration deficiency and employee file missing fingerprint and reference checks |
| DON | Director of Nursing | Named in medication administration, nail care, and infection prevention deficiencies |
| Administrator | Named in employee file review and dietary deficiencies | |
| DM | Dietary Manager | Named in dietary food handling and dumpster area deficiencies |
| SSD | Social Services Director | Named in Medicare notice and PASRR referral deficiencies |
| CC | Licensed Practical Nurse (LPN) | Named in nail care deficiency |
| AA | Certified Nursing Assistant (CNA) | Named in nail care deficiency |
| DD | Certified Medication Aide (CMA) | Named in infection prevention deficiency |
| EE | Certified Medication Aide (CMA) | Named in infection prevention deficiency |
| Maintenance Director | Named in environmental and dumpster area deficiencies |
Inspection Report
Annual Inspection
Census: 181
Deficiencies: 9
Date: Nov 8, 2024
Visit Reason
The inspection was conducted as part of the facility's annual survey to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to assess residents for safe self-administration of medications, failure to provide required notices to residents regarding Medicare coverage, failure to maintain a safe and clean environment, incomplete employee background checks, failure to refer residents for specialized mental health services, inadequate provision of activities of daily living such as nail care, improper food handling and storage practices, unsanitary dumpster area, and failure to clean reusable medical equipment between resident use.
Deficiencies (9)
Failed to ensure one resident was assessed to safely self-administer medications, leading to potential medication access risks.
Failed to appropriately provide Notice of Medicare Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice to one resident.
Failed to maintain a safe, clean, comfortable, homelike environment in two rooms, including issues with a circulating fan and bathroom ceiling stains.
Failed to obtain fingerprint and reference checks for several employees.
Failed to refer a resident with serious mental illness for Level II PASRR evaluation.
Failed to provide nail care for two residents as part of activities of daily living.
Failed to discard food items by expiration or use-by date, failed to discard food with mold, and failed to ensure dietary staff wore beard coverings.
Failed to maintain dumpster area in sanitary condition, with discarded items on the ground.
Failed to clean reusable medical equipment between resident use, risking spread of infection.
Report Facts
Residents sampled: 60
Facility census: 181
Employee files reviewed: 10
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 4
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Licensed Practical Nurse (LPN) | Named in medication self-administration deficiency and interview |
| GGG | Certified Medication Aide (CMA) | Named in medication self-administration deficiency and employee file review |
| DON | Director of Nursing | Named in medication self-administration deficiency, nail care deficiency, and infection control |
| Administrator | Named in employee file review and dietary deficiencies | |
| SSD | Social Services Director | Named in Medicare notice deficiency and PASRR referral deficiency |
| LPN CC | Licensed Practical Nurse | Named in nail care deficiency |
| CMA DD | Certified Medication Aide | Named in infection control deficiency |
| CMA EE | Certified Medication Aide | Named in infection control deficiency |
| DM | Dietary Manager | Named in food handling and dumpster area deficiencies |
| Maintenance Director | Named in environment and dumpster area deficiencies |
Inspection Report
Life Safety
Census: 181
Capacity: 186
Deficiencies: 2
Date: Nov 6, 2024
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements due to failure to maintain smoke separation between corridors and mechanical rooms, and multiple hazard doors on several floors that did not close and latch properly, potentially affecting resident safety.
Deficiencies (2)
Failed to maintain smoke separation between corridors and mechanical rooms due to open transom grills allowing smoke migration.
Multiple hazard doors on multiple floors were not self-closing and latching, including bio-hazard door, soiled utility door, laundry room door, and kitchen door.
Report Facts
Census: 181
Total Capacity: 186
Residents potentially affected: 50
Residents potentially affected: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour on 11/6/2024 |
Inspection Report
Complaint Investigation
Census: 176
Deficiencies: 0
Date: Aug 30, 2024
Visit Reason
A complaint survey was initiated on August 1, 2024, to investigate multiple complaints against the facility and concluded on August 30, 2024.
Complaint Details
Complaints GA00248222, GA00249058, and GA00249146 were unsubstantiated. Complaint GA00249114 was substantiated with no regulatory violations cited.
Findings
Three complaints were unsubstantiated, and one complaint was substantiated but with no regulatory violations cited.
Inspection Report
Deficiencies: 0
Date: Jul 3, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Legacy Transitional Care & Rehabilitation, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 3, 2024
Visit Reason
A revisit survey was conducted on 7/3/2024 to verify correction of deficiencies cited during the 5/16/2024 Recertification survey and to investigate Complaint Intake Number GA00246980.
Complaint Details
Complaint Intake Number GA00246980 was investigated and found to be unsubstantiated.
Findings
All deficiencies cited in the prior 5/16/2024 Recertification survey and Complaint Investigation were found to be corrected. The complaint was unsubstantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 3, 2024
Visit Reason
A revisit survey was conducted on 7/3/2024 to verify correction of deficiencies cited in the 5/16/2024 Recertification survey and to investigate Complaint Intake Number GA00246980.
Complaint Details
Complaint Intake Number GA00246980 was investigated and found to be unsubstantiated.
Findings
All deficiencies cited in the prior recertification survey and complaint investigation were found to be corrected. The complaint was unsubstantiated.
Inspection Report
Routine
Census: 179
Deficiencies: 8
Date: May 16, 2024
Visit Reason
A standard routine survey was conducted from May 14, 2024 through May 16, 2024, including investigation of two complaint intake numbers, one substantiated with deficiencies and one without.
Complaint Details
Complaint Intake Number GA00245101 was substantiated without deficiencies. Complaint Intake Number GA00245097 was substantiated with deficiencies related to the standard survey findings.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including unsafe and unclean environment conditions in resident rooms and bathrooms, failure in abuse prevention screening, incomplete baseline care plans, inadequate respiratory care, medication errors, improper medication storage, unsanitary food storage and preparation, and lapses in infection prevention and control practices.
Deficiencies (8)
Facility failed to provide a safe, clean, comfortable, and homelike environment with issues such as damaged walls, peeling paint, broken lighting, loose handrails, and unsanitary conditions in resident rooms and bathrooms.
Failure to ensure pre-employment fingerprint background checks for two staff members.
Failure to develop a baseline care plan including goals and interventions for a resident with pressure ulcers.
Failure to provide respiratory care consistent with professional standards, including unclean oxygen concentrator filters, lack of physician order for oxygen therapy, and improper storage of oxygen nasal cannula.
Medication error rate exceeded 5%, with two medication errors observed in 28 opportunities.
Failure to properly store medications, including medications left in a resident's room after discharge and medication left on a resident's bedside table.
Failure to ensure proper labeling, dating, and sanitation of food items and kitchen equipment, including dirty ice machines and unlabeled frozen foods.
Failure to ensure appropriate hand hygiene during meal tray passing and failure to sanitize point of care equipment after use.
Report Facts
Resident census: 179
Medication error rate: 7.14
Number of resident rooms with environment issues: 11
Number of bathrooms with environment issues: 10
Number of residents with specific environment issues: 2
Number of staff files missing fingerprint screening: 2
Number of residents receiving oxygen therapy reviewed: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NN | Certified Nursing Assistant | Hired without fingerprint background check |
| OO | Certified Medical Assistant | Hired without fingerprint background check |
| AA | Licensed Practical Nurse | Named in medication administration and infection control deficiencies |
| JJ | Licensed Practical Nurse (Agency) | Left medication with resident, violating medication administration policy |
| BB | Licensed Practical Nurse Unit Manager | Confirmed medication storage and administration deficiencies |
| MM | Licensed Practical Nurse | Interviewed regarding medication administration and resident care |
| CC | Medication Technician | Observed not sanitizing glucose meter properly |
| HH | Certified Nursing Assistant | Interviewed about hand hygiene practices during meal service |
| GG | Unit Manager | Confirmed hand hygiene expectations during meal service |
| DON | Director of Nursing | Provided multiple interviews regarding care plans, oxygen therapy, medication administration, and infection control |
| DM | Dietary Manager | Interviewed and observed regarding food storage and kitchen sanitation |
| MS | Maintenance Supervisor | Responsible for ice machine maintenance and pest control |
Inspection Report
Annual Inspection
Census: 179
Deficiencies: 4
Date: May 16, 2024
Visit Reason
A State Licensure survey was conducted at Legacy Transitional Care & Rehabilitation from May 14 through May 16, 2024, to assess compliance with state health regulations and facility licensure requirements.
Findings
The survey identified multiple deficiencies including improper medication storage and administration, inadequate hand hygiene and infection control practices, environmental sanitation issues with resident rooms and bathrooms, and food safety violations in the kitchen related to labeling, dating, and cleanliness of food items and equipment.
Deficiencies (4)
Failed to properly store medication for two of 66 sampled residents, placing residents, staff, and visitors at risk of unauthorized access.
Failed to ensure staff implemented appropriate hand hygiene during meal tray passing and failed to sanitize point of care equipment after use for two residents.
Failed to provide a safe, clean, comfortable, homelike environment for 11 of 84 resident rooms and 10 of 48 bathrooms, including issues such as damaged fixtures, peeling paint, broken equipment, and pest presence.
Failed to ensure food items were properly labeled, discard expired foods, and maintain cleanliness of kitchen equipment and ice machines.
Report Facts
Residents sampled: 66
Facility census: 179
Resident rooms inspected: 84
Bathrooms inspected: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN JJ | Licensed Practical Nurse (Agency) | Named in medication administration deficiency for leaving medication with resident |
| LPN AA | Licensed Practical Nurse | Observed failing to sanitize blood pressure cuff between residents |
| Med Tech CC | Medication Technician | Observed not consistently using barriers during fingerstick blood sugar procedure |
| DON | Director of Nursing | Provided policy information and confirmed expectations for medication administration and infection control |
| DM | Dietary Manager | Interviewed regarding food labeling, kitchen cleanliness, and food safety deficiencies |
| MS | Maintenance Supervisor | Responsible for cleaning and maintenance of ice machines; acknowledged deficiencies |
| Administrator | Facility Administrator | Interviewed regarding expectations for kitchen staff and overall facility operations |
Inspection Report
Annual Inspection
Census: 179
Deficiencies: 8
Date: May 16, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident safety, care, medication management, infection control, and facility environment.
Findings
The facility was found deficient in multiple areas including environmental safety hazards in resident rooms and bathrooms, incomplete care planning for pressure ulcers, failure to ensure proper pre-employment fingerprint screening, inadequate respiratory care including lack of physician orders and unclean oxygen equipment, medication errors exceeding 5%, improper medication storage, food safety violations including unlabeled and expired food items, and failure to implement proper infection prevention practices such as hand hygiene and equipment sanitization.
Deficiencies (8)
Facility failed to provide a safe, clean, comfortable, and homelike environment with multiple environmental hazards including damaged walls, ceilings, plumbing leaks, broken fixtures, missing baseboards, beeping smoke detectors, and privacy curtain issues.
Failure to ensure pre-employment fingerprint screening for two staff members.
Failure to develop a baseline care plan addressing pressure ulcers for one resident upon admission.
Failure to provide safe and appropriate respiratory care including lack of physician orders for oxygen therapy and unclean oxygen concentrator filters and tubing.
Medication error rate exceeded 5% with administration of multivitamin with minerals instead of multivitamin as ordered for two residents.
Failure to properly store medications including leaving medications of discharged resident at bedside and medication left with resident by agency nurse.
Failure to ensure food items were properly labeled, discard expired foods, and maintain clean kitchen equipment and ice machines.
Failure to implement infection prevention and control program including inadequate hand hygiene during meal service and failure to sanitize blood pressure cuffs and glucose meter between residents.
Report Facts
Facility census: 179
Medication error rate: 7.14
Residents affected by environmental hazards: 11
Bathrooms affected by environmental hazards: 10
Residents sampled for environmental hazards: 66
Residents affected by fingerprint screening deficiency: 2
Residents affected by care plan deficiency: 1
Residents receiving oxygen therapy: 14
Residents affected by respiratory care deficiency: 2
Residents affected by medication error: 2
Residents affected by medication storage deficiency: 2
Residents affected by infection control deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NN | Certified Nursing Assistant | Named in fingerprint background check deficiency |
| OO | Certified Medical Assistant | Named in fingerprint background check deficiency |
| PP | Licensed Practical Nurse | Named in care plan and respiratory care findings |
| AA | Licensed Practical Nurse | Named in oxygen therapy and medication administration findings |
| JJ | Licensed Practical Nurse (Agency) | Named in medication storage and administration deficiency |
| BB | Unit Manager | Interviewed regarding medication administration and medication storage deficiencies |
| MM | Licensed Practical Nurse | Named in medication administration and medication storage findings |
| CC | Medication Technician | Named in infection control deficiency related to fingerstick procedure |
| HH | Certified Nursing Assistant | Named in infection control deficiency related to hand hygiene |
| GG | 4th-floor Unit Manager | Interviewed regarding hand hygiene expectations |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including respiratory care, medication administration, infection control |
| MDS Director | Interviewed regarding care planning deficiencies | |
| DM | Dietary Manager | Interviewed regarding food storage and kitchen cleanliness deficiencies |
| MS | Maintenance Supervisor | Interviewed regarding ice machine cleaning and pest control |
Inspection Report
Life Safety
Census: 180
Capacity: 186
Deficiencies: 0
Date: May 14, 2024
Visit Reason
The visit was conducted as a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness Program requirements and Life Safety Code standards during the survey.
Inspection Report
Life Safety
Census: 180
Capacity: 186
Deficiencies: 0
Date: May 14, 2024
Visit Reason
The visit was conducted as a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness Program requirements and Life Safety Code standards during the survey.
Report Facts
Stories: 4
Construction Type: Type I (3,3,2) construction
Year Constructed: 1971
Fully Sprinklered: Yes
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 7, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Legacy Transitional Care & Rehabilitation following a survey completed on 05/07/2024.
Findings
The document contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 180
Deficiencies: 0
Date: May 7, 2024
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited during the 3/11/2024 Complaint Survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 3/11/2024; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the 3/11/2024 Complaint Survey were found to be corrected.
Report Facts
Census: 180
Inspection Report
Renewal
Deficiencies: 2
Date: Mar 11, 2024
Visit Reason
The inspection was a Licensure Survey initiated on 2024-02-19 and concluded on 2024-03-11 to assess compliance with licensure requirements for Legacy Transitional Care & Rehabilitation.
Findings
The survey identified deficiencies including failure to provide timely dental care to a resident (R8) despite physician orders and resident requests, and malfunctioning call light communication systems on the fourth floor that prevented residents from alerting staff for assistance.
Deficiencies (2)
Failure to ensure one resident (R8) received adequate assistance and support from social services with receiving urgent dental services.
Failure to ensure the call light communication system was functioning to alert staff that residents required assistance on the fourth floor.
Report Facts
Sampled residents: 30
Call light malfunction duration: 3
Date dental consult ordered: Nov 29, 2023
Date dental care finally received: Mar 4, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN GG | Staff Development Coordinator | Aware of call light system malfunction and educated staff on monitoring system |
| LPN UU | Charge Nurse | Confirmed call light system on fourth floor was not functioning |
| Maintenance Director | Aware of call light system issues and maintenance requests | |
| CNA AAA | Certified Nursing Assistant | Reported call light system not operational for three weeks |
| LPN WW | Licensed Practical Nurse | Reported call light system not operational for three weeks |
| Social Service Director | Confirmed resident R8 was on dental list but was not seen by dentist until almost 4 months later | |
| Administrator | Acknowledged call light system issues and unawareness of recent malfunction |
Inspection Report
Complaint Investigation
Census: 184
Deficiencies: 9
Date: Mar 11, 2024
Visit Reason
An abbreviated/partial extended survey was conducted from 2024-02-19 through 2024-03-11 investigating multiple complaint intakes related to resident abuse and facility compliance.
Complaint Details
The complaint investigation was triggered by multiple complaint intakes (GA00243269, GA00242934, GA00242771, GA00243368, GA00243433). Complaints GA00243269, GA00242934, GA00242771, and GA00243433 were substantiated with deficiencies cited. Immediate Jeopardy was identified related to failure to protect residents from physical abuse on the secured memory unit, existing since 2023-09-30.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with Immediate Jeopardy related to failure to protect residents from physical abuse on the secured memory unit. Additional deficiencies included failure to provide a safe, clean, comfortable environment, failure to ensure accuracy of assessments related to wandering behaviors, failure to provide adequate ADL care including toileting and nail care, failure to provide timely dental services, failure to monitor and document behaviors, and failure to maintain a functioning call light system on the fourth floor.
Deficiencies (9)
Failure to protect residents from physical abuse on the secured memory unit, including multiple resident-to-resident altercations and inadequate supervision of a wandering resident resulting in injury.
Failure to provide a safe, clean, comfortable, and homelike environment on two floors, including broken furniture, peeling paint, stained chairs, and missing privacy curtains.
Failure to ensure accuracy of comprehensive assessment addressing wandering behaviors for a resident involved in multiple altercations.
Failure to provide adequate ADL care for eight residents related to toileting and nail care.
Failure to monitor and document behaviors for a resident involved in multiple physical altercations due to wandering.
Failure to ensure a resident received adequate assistance and support from social services with receiving urgent dental services in a timely manner.
Failure to ensure timely dental services after multiple requests and complaints of mouth pain.
Failure of administration to provide protective oversight of the facility environment including adequate supervision for wandering residents and failure to protect residents from abuse on the secured memory unit. Failure to ensure call light communication system was functioning on the fourth floor.
Failure to ensure the call light communication system was functioning to alert staff that residents required assistance on the fourth floor.
Report Facts
Residents involved in abuse: 8
Residents identified as wanderers: 35
Staff in-serviced on abuse and behavior management: 56
Residents assessed for skin: 63
Residents with ADL deficiencies: 8
Residents in sample: 30
Facility census: 184
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN TT | Licensed Practical Nurse | Observed and interviewed regarding resident nail care and wandering behaviors. |
| CNA AAA | Certified Nursing Assistant | Reported call light system malfunction and resident care concerns. |
| Administrator | Informed of Immediate Jeopardy, participated in corrective action planning and interviews. | |
| Director of Nursing | Informed of Immediate Jeopardy, participated in corrective action planning and interviews. | |
| Social Services Director | Interviewed regarding dental services and abuse oversight. | |
| Nurse Practitioner RR | Nurse Practitioner | Interviewed regarding resident behaviors and need for surveillance. |
| Physician Assistant QQ | Physician Assistant | Interviewed regarding resident behaviors and medication adjustments. |
| Maintenance Director | Interviewed regarding call light system malfunction. | |
| RN KKK | Registered Nurse | Conducted staff education on abuse and behavior management. |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Feb 20, 2024
Visit Reason
The inspection was conducted due to complaints and concerns regarding resident safety, abuse, wandering behaviors, inadequate care, and malfunctioning call light system at the facility.
Complaint Details
The complaint investigation revealed multiple issues including resident-to-resident abuse involving resident R1, failure to monitor wandering behaviors, inadequate ADL care, delayed dental services, and malfunctioning call light system. Immediate Jeopardy was identified on 2/28/2024 and removed on 3/2/2024 after corrective actions.
Findings
The facility failed to provide a safe, clean, and homelike environment, failed to protect residents from abuse including resident-to-resident altercations, failed to accurately assess and monitor wandering behaviors, failed to provide adequate ADL care including nail care and toileting assistance, failed to provide timely dental services, and failed to maintain a functioning call light system on the fourth floor. Immediate Jeopardy was identified and removed after corrective actions including staff education, care plan updates, behavioral monitoring, and administrative oversight.
Deficiencies (8)
Failed to provide a safe, clean, comfortable, and homelike environment on two floors with broken furniture, peeling paint, broken privacy curtains, and stained furniture.
Failed to protect eight residents from abuse including physical altercations involving resident R1 and others, resulting in Immediate Jeopardy.
Failed to ensure the accuracy of comprehensive assessment addressing wandering behaviors for resident R1, who was involved in multiple altercations and sustained injury.
Failed to provide adequate Activities of Daily Living care including toileting and nail care for eight residents.
Failed to provide medically-related social services to assist resident R8 with urgent dental services in a timely manner.
Failed to provide routine and 24-hour emergency dental care timely for resident R8 after multiple requests and complaints of mouth pain.
Failed to provide protective oversight of the facility environment including supervision for wandering residents and failed to maintain a functioning call light system on the fourth floor.
Failed to maintain a working call light system in residents' bathrooms and bathing areas on the fourth floor.
Report Facts
Residents affected by abuse: 8
Residents identified as wanderers: 35
Residents with ADL care issues: 8
Staff educated on abuse and behavioral management: 56
Residents assessed in skin assessment audit: 63
Residents in locked unit: 64
Days call light system malfunctioned: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| R1 | Resident | Involved in multiple resident-to-resident altercations and wandering behaviors. |
| Administrator | Acknowledged issues with furniture, wandering resident supervision, and call light system; participated in corrective action plans. | |
| Director of Nursing (DON) | Involved in abuse investigations, staff education, and oversight of corrective actions. | |
| Certified Nursing Assistant (CNA) AAA | CNA | Reported call light system malfunction and resident care concerns. |
| Licensed Practical Nurse (LPN) UU | Charge Nurse | Confirmed call light system malfunction on fourth floor. |
| Physician Assistant (PA) QQ | Physician Assistant | Aware of resident R1's behaviors and aggressive incidents. |
| Nurse Practitioner (NP) RR | Nurse Practitioner | Monitored resident R1 and confirmed need for closer surveillance. |
| Social Services Director (SSD) | Social Services Director | Responsible for assisting resident R8 with dental services; acknowledged delays. |
| Staff Development Coordinator LPN GG | Staff Development Coordinator | Educated staff on call light system and abuse policies. |
| Licensed Practical Nurse (LPN) TT | LPN | Observed residents with untrimmed nails and confirmed care deficiencies. |
Inspection Report
Abbreviated Survey
Census: 172
Deficiencies: 0
Date: Jan 11, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00242437, GA00242435, GA00242315, and GA00242374.
Complaint Details
The survey investigated complaints GA00242437, GA00242435, GA00242315, and GA00242374; no deficiencies were found related to these complaints.
Findings
No deficiencies were cited related to the complaints investigated during this survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 29, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Legacy Transitional Care & Rehabilitation, summarizing deficiencies identified during the inspection completed on 11/29/2023.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 176
Deficiencies: 0
Date: Nov 29, 2023
Visit Reason
A revisit survey was conducted at Legacy Transitional Care and Rehabilitation on November 29, 2023, including investigation of two complaint intake numbers GA00240222 and GA00241005.
Complaint Details
Complaint intake GA00240222 was unsubstantiated with no deficiencies cited; GA00241005 was substantiated without deficiencies cited.
Findings
All deficiencies cited in the October 13, 2023 survey were found to be corrected. The complaint investigation found GA00240222 to be unsubstantiated with no deficiencies cited and GA00241005 to be substantiated without deficiencies cited.
Report Facts
Facility census: 176
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 29, 2023
Visit Reason
A revisit survey was conducted on 11/29/2023 to verify correction of deficiencies cited in the 10/13/2023 recertification survey and to investigate two complaint intake numbers GA00241005 and GA00240222.
Complaint Details
Complaint Intake Number GA00241005 was substantiated with no deficiencies; Complaint Intake Number GA00240222 was unsubstantiated.
Findings
All deficiencies cited in the 10/13/2023 recertification survey were found to be corrected. The complaint investigation found GA00240222 was unsubstantiated and GA00241005 was substantiated with no deficiencies.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 28, 2023
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up survey.
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Oct 13, 2023
Visit Reason
A State Licensure survey was conducted at Legacy Transitional Care and Rehabilitation from October 10, 2023 through October 13, 2023 to assess compliance with state health regulations and standards.
Findings
The facility failed to ensure proper medication administration and documentation for two of 35 sampled residents and failed to maintain a safe, clean, and homelike environment in twelve of 84 resident rooms, including unclean conditions, broken tiles, unsafe surfaces, and unsecured mechanical room doors.
Deficiencies (2)
Failure to ensure medications were documented and administered according to professional standards for two residents (R7 and R100).
Failure to maintain a safe, clean, comfortable, homelike environment in twelve resident rooms with issues such as unclean conditions, broken tile, unsafe surfaces, and unsecured mechanical room doors.
Report Facts
Residents sampled for medication administration: 35
Resident rooms with environmental deficiencies: 12
Total resident rooms assessed for environment: 84
Date survey completed: Oct 13, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN EE | Licensed Practical Nurse | Interviewed regarding medication administration and confirmed resident R100 was not assessed for self-administration. |
| LPN CC | Licensed Practical Nurse | Observed administering medications and explained documentation practices. |
| LPN DD | 400 Unit Manager | Interviewed about nurse training on medication administration and documentation. |
| LPN LL | Licensed Practical Nurse | Interviewed about mechanical room door security on the secured memory care unit. |
| MA MM | Maintenance Assistant | Interviewed about mechanical room door being left open during contractor work. |
| Housekeeper B | Housekeeper | Interviewed about cleaning practices and lack of deep cleaning training. |
| HS NN | Housekeeping Supervisor | Interviewed about housekeeping department transition from outside contractor to in-house staff. |
| HM MM | Housekeeping Manager | Interviewed about staffing challenges in housekeeping department. |
| DON | Director of Nursing | Interviewed about facility administration, quality assurance plans, and housekeeping contract termination. |
Inspection Report
Routine
Census: 175
Capacity: 84
Deficiencies: 2
Date: Oct 10, 2023
Visit Reason
A standard survey was conducted from October 10 through October 13, 2023, including investigation of three complaint intake numbers, to assess compliance with Medicare/Medicaid regulations for Legacy Transitional Care and Rehabilitation.
Complaint Details
Complaint Intake numbers GA00239112 and GA00239469 were unsubstantiated. Complaint Intake number GA00238638 was substantiated with deficiency cited.
Findings
The facility was found not in substantial compliance with regulations due to unclean and unsafe conditions in twelve resident rooms and shower areas, and deficiencies in medication administration documentation and practices for two residents.
Deficiencies (2)
Facility failed to maintain a safe, clean, comfortable, homelike environment in twelve resident rooms and shower areas, including unclean conditions, broken tile, unsafe surfaces, and unlocked mechanical door.
Facility failed to ensure medications were documented and administered according to professional standards for two residents.
Report Facts
Resident census: 175
Total licensed capacity: 84
Number of residents sampled for medication review: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LL | Licensed Practical Nurse (LPN) | Interviewed regarding mechanical room door and medication administration |
| MM | Maintenance Assistant (MA) and Housekeeping Manager (HM) | Provided information about mechanical room door and housekeeping staffing |
| B | Housekeeper | Interviewed about cleaning practices |
| NN | Housekeeping Supervisor (HS) | Interviewed about housekeeping department transition |
| DON | Director of Nursing | Interviewed about facility administration and quality assurance plans |
| AA | Certified Nursing Assistant (CNA) | Observed and interviewed regarding medication found on floor |
| EE | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration and resident assessment |
| CC | Licensed Practical Nurse (LPN) | Observed administering medications and interviewed about documentation practices |
| DD | 400 Unit Manager Licensed Practical Nurse (LPN) | Interviewed about nurse training on medication administration and documentation |
Inspection Report
Life Safety
Census: 171
Capacity: 186
Deficiencies: 5
Date: Oct 10, 2023
Visit Reason
The inspection was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, including issues with fire alarm system testing and maintenance, corridor door smoke resistance, smoke barrier construction, fire drills documentation, and emergency electrical power testing.
Deficiencies (5)
Fire alarm system was not properly tested and maintained; no 2023 annual fire alarm report and no in-date smoke detector sensitivity testing.
Resident room doors did not latch closed or had gaps that would not resist smoke passage.
Facility failed to assure smoke resistance through corridor rated walls due to a loose fire caulk penetration.
Facility failed to maintain regular and documented fire drills; missing July 2023 and September 2023 fire drill reports.
Facility failed to assure emergency electrical power met minimum requirements; no record of 4-hour load testing on the generator as required.
Report Facts
Smoke Compartments affected: 1
Census: 171
Total Capacity: 186
Missing fire drill reports: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Routine
Deficiencies: 2
Date: Oct 10, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to the safety, cleanliness, and quality of care at Legacy Transitional Care & Rehabilitation.
Findings
The facility failed to maintain a safe, clean, and homelike environment in multiple resident rooms and shower areas, with issues including unclean conditions, broken tiles, unsafe surfaces, and improper medication administration practices for some residents.
Deficiencies (2)
Failed to maintain a safe, clean, comfortable, homelike environment in twelve of 84 resident rooms with unclean conditions, broken tile, and unsafe surfaces; mechanical room door left open and unlocked.
Failed to ensure medications were documented and administered according to professional standards for two of 35 sampled residents.
Report Facts
Residents affected: 12
Residents sampled: 35
Residents affected: 2
Residents affected: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN LL | Licensed Practical Nurse | Interviewed regarding mechanical room door security and medication administration |
| MA MM | Maintenance Assistant | Interviewed regarding mechanical room door being left open |
| Housekeeper B | Housekeeper | Interviewed about cleaning practices and training |
| HS NN | Housekeeping Supervisor | Interviewed about housekeeping department transition and cleaning schedule |
| HM MM | Housekeeping Manager | Interviewed about housekeeping staffing and contract termination |
| DON | Director of Nursing | Interviewed about housekeeping contract termination and QA plans |
| CNA AA | Certified Nursing Assistant | Observed and interviewed regarding medication found on floor |
| LPN EE | Licensed Practical Nurse | Interviewed regarding medication administration and resident assessment |
| LPN CC | Licensed Practical Nurse | Observed administering medications and interviewed about documentation practices |
| LPN DD | 400 Unit Manager | Interviewed about nurse training on medication administration and documentation |
Inspection Report
Deficiencies: 0
Date: Sep 13, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Legacy Transitional Care & Rehabilitation, indicating a regulatory inspection was conducted.
Findings
No deficiencies or findings are listed in the report; the statement of deficiencies section is blank.
Inspection Report
Re-Inspection
Census: 180
Deficiencies: 0
Date: Sep 13, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the August 10, 2023 Complaint Survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on August 10, 2023; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the August 10, 2023 Complaint Survey were found to be corrected.
Report Facts
Census: 180
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 10, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Legacy Transitional Care & Rehabilitation following a survey completed on August 10, 2023.
Findings
The report contains initial comments but does not specify any detailed deficiencies or findings.
Inspection Report
Re-Inspection
Census: 175
Deficiencies: 0
Date: Aug 10, 2023
Visit Reason
A revisit survey was conducted from August 8 through August 10, 2023, to verify correction of deficiencies cited in a June 16, 2023 complaint survey and to investigate complaint intake numbers GA00235947, GA00236150, and GA00236501.
Complaint Details
Complaint intake numbers GA00235947, GA00236150, and GA00236501 were investigated in conjunction with this revisit survey. Deficient practice was identified related to the complaint investigation.
Findings
All deficiencies cited in the June 16, 2023 complaint survey were found to be corrected; however, deficient practice related to the complaint investigation was identified, and the facility was not in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, subpart B.
Report Facts
Resident census: 175
Inspection Report
Renewal
Deficiencies: 3
Date: Aug 10, 2023
Visit Reason
A Licensure Survey was conducted from August 8, 2023 through August 10, 2023 to assess compliance with licensure requirements.
Findings
The facility failed to appropriately store medications in three of six medication carts and one of three medication rooms, including unlocked medication carts left unattended and insulin vials used beyond recommended storage durations.
Deficiencies (3)
Medication carts were left unlocked and unattended with medications left on top of carts.
Medication room keys were given to unlicensed staff (CNA), contrary to policy.
Multiple insulin vials and ophthalmic drops were stored beyond manufacturer recommended usage periods or lacked open date labeling.
Report Facts
Days insulin vials in use: 137
Days insulin vials in use: 60
Days insulin vials in use: 50
Days insulin vials in use: 47
Days insulin vials in use: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse FF | Licensed Practical Nurse | Assigned to Fourth Floor Medication Cart #1, confirmed cart was left unlocked and unattended |
| Certified Medication Aide-Technician GG | Certified Medication Aide-Technician | Assigned to Fourth Floor Medication Cart #2, confirmed cart was locked but medication cup left on top |
| Certified Nursing Assistant CC | Certified Nursing Assistant | Received medication room keys from LPN EE, contrary to policy |
| Unit Manager DD | Unit Manager | Stated nurses should not give medication room keys to CNAs and confirmed medication storage policies |
| LPN EE | Licensed Practical Nurse | Handed medication room keys to CNA CC |
| LPN HH | Licensed Practical Nurse | Confirmed vial of Lantus was labeled with open date but unsure of medication expiration |
| Certified Medication Aide-Technician II | Certified Medication Aide-Technician | Verified multiple insulin vials and ophthalmic drops with missing or outdated open dates |
| Administrator | Stated expectation that nursing staff follow manufacturer recommendations for medication storage | |
| Director of Nursing | Stated expectation that medication carts be locked when unattended and medication room keys maintained by licensed nurses |
Inspection Report
Abbreviated Survey
Census: 175
Deficiencies: 2
Date: Aug 10, 2023
Visit Reason
An abbreviated/partial extended survey was conducted from August 8 through August 10, 2023, investigating complaints GA00235947, GA00236150, and GA00236501, and included a revisit survey.
Complaint Details
The survey was complaint-related, investigating complaints GA00235947, GA00236150, and GA00236501. The facility was found noncompliant related to the complaint survey.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to appropriately store medications in multiple medication carts and rooms, and failure to provide a functioning call system in 19 of 84 rooms.
Deficiencies (2)
Failure to appropriately store medications in three of six medication carts and one of three medication rooms, including unlocked carts, medications left unattended, and insulin vials used beyond recommended storage times.
Failure to provide a functioning call system for 19 of 84 rooms in the building, with call lights not working or missing entirely.
Report Facts
Resident census: 175
Rooms with non-functioning call system: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse FF | Licensed Practical Nurse | Assigned to Fourth Floor Medication Cart #1; confirmed cart was left unlocked and unattended |
| Certified Medication Aide-Technician GG | Certified Medication Aide-Technician | Assigned to Fourth Floor Medication Cart #2; confirmed medication cup left on cart |
| Certified Nursing Assistant CC | Certified Nursing Assistant | Observed receiving medication room keys from LPN EE |
| LPN EE | Licensed Practical Nurse | Handed medication room keys to CNA CC |
| Unit Manager DD | Unit Manager | Reported nurses should not give medication room keys to CNAs; confirmed call light issues |
| LPN HH | Licensed Practical Nurse | Confirmed vial of Lantus insulin was labeled with an open date beyond recommended use |
| Certified Medication Aide-Technician II | Certified Medication Aide-Technician | Confirmed multiple insulin vials and ophthalmic drops were stored improperly or unlabeled |
| Administrator | Administrator | Stated expectations for medication storage and call light maintenance |
| Director of Nursing | Director of Nursing | Stated expectations for medication storage and call light maintenance |
| Wound Care Manager | Wound Care Manager | Confirmed call light in room 212 was not working properly |
| Wound Care Treatment Tech | Wound Care Treatment Technician | Confirmed call light in room 212 was not working properly |
| Certified Nursing Assistant AA | Certified Nursing Assistant | Reported no call light in room 224 and prior reports to charge nurse and unit manager |
| Unit Manager BB | Unit Manager | Expected staff to report non-working call lights to maintenance and herself |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 10, 2023
Visit Reason
The inspection was conducted based on complaints regarding improper medication storage and malfunctioning call light systems in the facility.
Complaint Details
The visit was complaint-related, triggered by concerns about medication storage practices and non-functioning call light systems. Substantiation status is not explicitly stated.
Findings
The facility failed to appropriately store medications securely and according to manufacturer guidelines, with multiple medication vials being used beyond recommended timeframes and medication carts left unlocked or unattended. Additionally, the facility failed to provide functioning call light systems in 19 of 84 resident rooms, impacting residents' ability to summon assistance.
Deficiencies (2)
Medication carts were left unlocked and unattended, and medications were stored beyond recommended usage periods or without proper labeling.
Call light systems were not functioning in 19 resident rooms, preventing residents from effectively calling for assistance.
Report Facts
Medication vials in use beyond recommended days: 137
Number of rooms with non-functioning call lights: 19
Number of medication carts with storage issues: 3
Number of medication rooms with storage issues: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse FF | Licensed Practical Nurse | Assigned to Fourth Floor Medication Cart #1, confirmed cart was left unlocked and unattended. |
| Certified Medication Aide-Technician GG | Certified Medication Aide-Technician | Assigned to Fourth Floor Medication Cart #2, confirmed cart was locked but medication cup was left on top. |
| Certified Nursing Assistant CC | Certified Nursing Assistant | Asked for Third Floor Medication Room keys and received them from LPN EE. |
| Unit Manager DD | Unit Manager | Stated nurses should not give medication room keys to CNAs and confirmed expectations for medication storage and call light repairs. |
| Licensed Practical Nurse HH | Licensed Practical Nurse | Confirmed vial of Lantus was labeled with an open date but was unsure of medication expiration after opening. |
| Certified Medication Aide-Technician II | Certified Medication Aide-Technician | Confirmed multiple medication vials with improper labeling or expired usage. |
| Administrator | Administrator | Expected nursing staff to follow manufacturer recommendations for medication storage and immediate repair of call lights. |
| Director of Nursing | Director of Nursing | Expected nursing staff to follow manufacturer recommendations for medication storage and immediate repair of call lights. |
| Certified Nursing Assistant AA | Certified Nursing Assistant | Reported absence of call light in a resident room and confirmed prior reporting to charge nurse and unit manager. |
| Unit Manager BB | Unit Manager | Expected staff to report non-working call lights to maintenance and herself, described reporting process. |
| Wound Care Manager | Confirmed call light was not working properly. | |
| Wound Care Treatment Tech | Confirmed call light was not working properly. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 24, 2023
Visit Reason
The facility was reviewed for compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network during a seven-day period.
Findings
The facility failed to report complete COVID-19 information to the CDC's NHSN between 07/17/2023 and 07/23/2023 as required by CMS and CDC regulations, potentially causing more than minimal harm to residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 17, 2023
Visit Reason
The facility was reviewed for failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 07/10/2023 and 07/16/2023 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's NHSN during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Renewal
Deficiencies: 2
Date: Jun 16, 2023
Visit Reason
A Licensure Survey was conducted from June 13, 2023 through June 16, 2023 on behalf of the Georgia Department of Community Health to assess compliance with licensure requirements.
Findings
The facility failed to appropriately discharge a resident by not providing required written notice to the resident's representative and ombudsman. Additionally, the facility failed to maintain a clean and sanitary environment, with observations of strong urine odors, flying insects, soiled linens, and dirty resident rooms on one of three floors.
Deficiencies (2)
Failure to provide written notice of discharge to resident's representative and ombudsman as required by regulation.
Failure to maintain a clean and sanitary environment including strong urine odors, presence of flying insects, soiled linens, and dirty resident rooms.
Report Facts
Dates of survey: Survey conducted from 2023-06-13 through 2023-06-16
Resident ID: 6
BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Admissions Coordinator | Interviewed regarding resident discharge and return | |
| Social Service Director | Interviewed regarding discharge process and documentation | |
| Administrator | Interviewed regarding discharge notice issuance |
Inspection Report
Complaint Investigation
Census: 172
Deficiencies: 5
Date: Jun 16, 2023
Visit Reason
An abbreviated/partial extended survey was conducted to investigate multiple complaints against the facility, initiated on June 13, 2023 and concluded on June 16, 2023.
Complaint Details
The survey was initiated due to multiple complaints (GA00226605, GA00228135, GA00229694, GA00230250, GA00232038, GA00232053, GA00232078, GA00232823, GA00234670, and GA00235247). The complaint investigation substantiated issues including neglect of resident R#2 and improper discharge procedures for resident R#6.
Findings
The facility was found to have multiple deficiencies including failure to maintain clean and comfortable living spaces, failure to prevent abuse and neglect of residents, failure to properly notify and document a facility-initiated discharge, unsanitary garbage disposal areas, and ineffective pest control program evidenced by presence of flying insects throughout the facility.
Deficiencies (5)
Facility failed to maintain clean and comfortable living spaces on the fourth floor, dining room, and main floor entrance with strong urine odors, dirty dining areas, and soiled resident rooms.
Facility failed to ensure one resident was free from abuse and/or neglect, including failure to provide adequate personal care and hygiene.
Facility failed to appropriately discharge a resident by not notifying the resident's representative and ombudsman in writing and in a manner they understand.
Facility failed to maintain the garbage disposal area in a sanitary manner with heavy accumulation of trash and open bags attracting insects.
Facility failed to maintain an effective pest control program as evidenced by presence of multiple small flying insects throughout the building.
Report Facts
Resident census: 172
Resident weight: 439
BIMS score: 3
Number of complaints investigated: 10
Number of staff to move resident: 8
Number of sampled residents in abuse finding: 4
Number of sampled residents in discharge finding: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DD | Unit Manager | Interviewed regarding care and bathing of resident R#2 |
| Administrator | Interviewed regarding discharge procedures for resident R#6 and trash removal schedule | |
| Admissions Coordinator | Interviewed regarding discharge and readmission of resident R#6 | |
| Social Service Director | Interviewed regarding discharge process and documentation for resident R#6 | |
| Maintenance Manager | Interviewed regarding trash pickup and cleanliness of garbage disposal area |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jun 13, 2023
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to maintain a clean, safe, and homelike environment, protect residents from abuse and neglect, ensure proper discharge notification, maintain sanitary garbage disposal, and implement an effective pest control program.
Complaint Details
The complaint investigation focused on allegations of unsanitary conditions, neglect of resident care, failure to notify about discharge, improper garbage disposal, and pest infestation. The investigation substantiated neglect of resident R#2 and failure to notify about discharge of resident R#6.
Findings
The facility was found to have multiple deficiencies including unsanitary living conditions with strong urine and fecal odors, presence of flying insects, neglect of resident personal care, failure to notify resident representatives of discharge, accumulation of garbage outside, and ineffective pest control measures.
Deficiencies (5)
Failed to maintain clean and comfortable living spaces for residents on the fourth floor, dining room, and main floor entrance, including strong urine and bowel movement odors and presence of flying insects.
Failed to protect residents from abuse and neglect, specifically neglecting one resident who refused staff care and was left with soiled bedding and poor hygiene.
Failed to provide timely notification to resident's representative and ombudsman before transfer or discharge, including appeal rights, for one resident discharged after a physical altercation.
Failed to maintain the garbage disposal area in a sanitary manner, with heavy accumulation of trash, open bags, and flying insects around the dumpster area.
Failed to maintain an effective pest control program as evidenced by the presence of small flying pests throughout the facility.
Report Facts
Resident weight: 439
Number of staff needed to move resident: 8
Brief Interview for Mental Status (BIMS) score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DD | Unit Manager | Interviewed regarding care and bathing of resident R#2 |
| Administrator | Administrator | Interviewed regarding discharge notification for resident R#6 and garbage pickup |
| MM | Maintenance Manager | Interviewed regarding garbage pickup and cleanliness of dumpster area |
| SSD | Social Service Director | Interviewed regarding discharge process and documentation for resident R#6 |
Inspection Report
Re-Inspection
Census: 168
Deficiencies: 0
Date: Dec 1, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the September 24, 2022, Recertification and Complaint Investigation survey.
Complaint Details
The revisit was related to a prior Complaint Investigation survey conducted on September 24, 2022.
Findings
All deficiencies cited as a result of the September 24, 2022, Recertification in conjunction with a Complaint Investigation survey were found to be corrected.
Inspection Report
Re-Inspection
Census: 168
Deficiencies: 0
Date: Dec 1, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the September 24, 2022, Recertification in conjunction with a Complaint Investigation survey.
Complaint Details
The revisit survey followed a Complaint Investigation survey conducted on September 24, 2022.
Findings
All deficiencies cited as a result of the September 24, 2022 survey were found to be corrected.
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Sep 24, 2022
Visit Reason
The inspection was conducted as a Licensure Survey from August 1, 2022 through September 24, 2022, to assess compliance with state and federal regulations related to infection control, resident care, safety, and other regulatory requirements.
Findings
The facility was found out of compliance with multiple requirements including failure to effectively implement COVID-19 infection control measures, failure to provide adequate supervision during mealtime for residents at risk of aspiration, failure to provide physician-ordered thickened liquids, failure to investigate a mechanical lift fall, failure to maintain sanitary kitchen conditions, and failure to update and provide pneumonia vaccinations according to current CDC guidelines. Immediate Jeopardy was identified and subsequently removed after the facility implemented corrective actions and ongoing oversight.
Deficiencies (7)
Failure to provide oversight and monitoring of the Infection Control Program, including improper COVID-19 outbreak testing, cohorting, and staff testing.
Failure to implement care plan for resident at risk for aspiration, resulting in resident left unsupervised during meal and found in respiratory distress.
Failure to provide physician ordered thickened liquids for resident at risk for aspiration.
Failure to thoroughly investigate a fall from a mechanical lift and implement effective interventions.
Failure to maintain sanitary kitchen conditions including blood spill on floor not promptly cleaned and dirty fan blowing toward clean dishes.
Failure to ensure food items were sealed and dated properly.
Failure to update pneumonia vaccination policy with current CDC recommendations and failure to offer or provide pneumonia vaccinations to applicable residents.
Report Facts
COVID-19 positive residents: 40
Unvaccinated staff: 15
Staff tested for COVID-19: 45
Residents tested for COVID-19: 167
Staff educated on COVID-19 testing: 124
Staff completed education: 68
Employees fit tested for N95: 55
Staff COVID-19 screenings missing: 19
Staff COVID-19 screenings missing: 39
Staff COVID-19 screenings missing: 6
Staff COVID-19 screenings missing: 33
Staff COVID-19 screenings missing: 34
Staff COVID-19 screenings missing: 20
Staff in-service completion: 58
Staff in-service completion percentage: 85
Residents at risk for aspiration: 10
Residents receiving meals from kitchen: 166
Pneumonia vaccine doses ordered: 6
Facility census: 175
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN LL | Licensed Practical Nurse | Responded to resident in respiratory distress and provided oxygen and suction. |
| Nurse Manager RR | Nurse Manager | Assisted with resident in respiratory distress and contacted physician. |
| CNA NN | Certified Nursing Assistant | Assigned to feed resident at risk for aspiration but left resident unsupervised. |
| LPN UM DD | Licensed Practical Nurse Unit Manager | Observed resident receiving wrong liquid consistency and confirmed diet orders. |
| Speech Therapist SS | Speech Therapist | Provided swallowing evaluation and recommended supervision during meals. |
| Dietary Manager XX | Dietary Manager | Confirmed food items were not dated and thickened liquids were not provided. |
| Director of Nursing | Director of Nursing | Oversight of infection control, staff education, and resident care plans. |
| Assistant Director of Nursing | Assistant Director of Nursing | Responsible for tracking immunizations and ensuring vaccinations offered. |
| Pharmacy Director | Pharmacy Director | Reported no pneumonia vaccine orders since May 2021. |
| Maintenance Director | Maintenance Director | Uncertain about responsibility for cleaning kitchen fan. |
Inspection Report
Abbreviated Survey
Census: 175
Deficiencies: 9
Date: Sep 24, 2022
Visit Reason
A standard survey was conducted from August 1 through August 7, 2022, including investigation of multiple complaint intake numbers, to assess compliance with Medicare/Medicaid regulations and infection control practices during a COVID-19 outbreak.
Complaint Details
The survey included investigation of multiple complaint intake numbers, some of which were substantiated with deficiencies related to infection control and resident care.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to implement effective COVID-19 infection control measures, inadequate supervision during meals leading to aspiration, failure to ensure resident rights regarding visitation, resident-to-resident abuse, failure to complete PASARR Level II screenings, inadequate food safety practices, and failure to properly conduct COVID-19 testing and cohorting during an outbreak.
Deficiencies (9)
Failure to implement effective COVID-19 infection control measures including contact tracing, staff fit testing for N95 masks, proper PPE use, and cohorting of COVID-positive and negative residents during an outbreak.
Failure to provide adequate supervision during meals for resident at risk for aspiration, resulting in respiratory distress and hospitalization.
Failure to promote resident rights by requiring family members to schedule visits in advance and limiting visitation times.
Failure to prevent resident-to-resident physical abuse.
Failure to complete PASARR Level II screenings for residents newly diagnosed with serious mental disorders.
Failure to ensure food safety including sealing and dating opened food items, maintaining sanitary kitchen conditions, and promptly cleaning blood spills.
Failure to provide pneumococcal vaccinations according to current CDC recommendations and failure to update facility policy accordingly.
Failure to conduct COVID-19 testing for residents and staff according to CDC and CMS guidelines, including outbreak testing and routine testing of unvaccinated staff.
Failure to maintain an effective Quality Assurance and Performance Improvement (QAPI) program to identify and correct infection control deficiencies.
Report Facts
Resident census: 175
Residents tested positive for COVID-19: 40
Unvaccinated employees: 15
Staff in-service attendance: 58
Staff fit tested for N95 masks: 55
Staff COVID-19 screening compliance: 49
Staff COVID-19 screening compliance: 32
Staff COVID-19 screening compliance: 29
Staff COVID-19 screening compliance: 29
Staff COVID-19 screening compliance: 37
Staff COVID-19 screening compliance: 16
Staff COVID-19 testing: 45
Staff COVID-19 positive test results: 1
Resident COVID-19 testing: 167
Resident COVID-19 positive test results: 20
Staff education attendance: 124
Staff education attendance: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN LL | Licensed Practical Nurse | Provided emergency care to resident R#25 during respiratory distress |
| Nurse Manager RR | Nurse Manager | Assisted with emergency care of resident R#25 and coordinated emergency room transfer |
| CNA NN | Certified Nursing Assistant | Observed resident R#25 during meal, noted resident left unsupervised |
| NP TT | Nurse Practitioner | Provided medical assessment and care recommendations for resident R#25 |
| ST SS | Speech Therapist | Provided swallowing therapy and care recommendations for resident R#25 |
| DON | Director of Nursing | Oversight of infection control program and COVID-19 outbreak response |
| ADON | Assistant Director of Nursing | Oversight of infection control program and COVID-19 outbreak response |
| DM XX | Dietary Manager | Responsible for food safety and diet order compliance |
| LPN Manager AA | Licensed Practical Nurse Manager | Oversight of staff PPE use and infection control |
| CNA HH | Certified Nursing Assistant | Assisted with resident separation during resident-to-resident abuse incident |
| UM DD | Unit Manager | Witnessed resident-to-resident abuse incident and assisted with separation |
| SW | Social Worker | Responsible for PASARR screening and resident rights advocacy |
| DSW | Director of Social Work | Responsible for PASARR screening and resident rights advocacy |
| Regional Director | Regional Director of Clinical Operations | Provided staff education and oversight of infection control program |
Inspection Report
Life Safety
Census: 171
Capacity: 186
Deficiencies: 0
Date: Aug 3, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 standard.
Findings
The facility was found to be in compliance with the Emergency Preparedness Program requirements and Life Safety Code standards during the survey.
Report Facts
Stories: 4
Construction Type: Type I (3,3,2) construction
Year Constructed: 1971
Certified beds: 186
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 14, 2021
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Legacy Transitional Care & Rehabilitation following a survey completed on October 14, 2021.
Findings
The document contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 14, 2021
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited in the July 23, 2021 Complaint Survey.
Complaint Details
This revisit survey followed a complaint survey conducted on July 23, 2021, and confirmed all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the July 23, 2021 Complaint Survey were found to be corrected.
Inspection Report
Abbreviated Survey
Census: 165
Deficiencies: 0
Date: Aug 10, 2021
Visit Reason
An Abbreviated Survey was conducted to investigate complaints #GA00216440 and #GA00216406.
Complaint Details
Complaints #GA00216440 and #GA00216406 were substantiated with no deficiencies.
Findings
The complaints #GA00216440 and #GA00216406 were substantiated with no deficiencies found during the survey.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Aug 10, 2021
Visit Reason
The visit was conducted as a licensure survey for the facility.
Findings
No deficiencies were identified during the licensure survey conducted from 7/20/2021 through 7/23/2021.
Inspection Report
Abbreviated Survey
Census: 165
Deficiencies: 2
Date: Aug 10, 2021
Visit Reason
An Abbreviated Survey was conducted from 8/9/2021 to 8/10/2021 to verify removal of Immediate Jeopardy identified during a prior survey and to investigate complaint intakes GA00216440 and GA00216406.
Complaint Details
Complaint intake numbers GA00216440 and GA00216406 were investigated and substantiated with no deficiencies.
Findings
The facility failed to provide adequate supervision to prevent sexual abuse of residents, failed to notify the State Survey Agency within the required two-hour timeframe of alleged abuse incidents, and failed to follow up with psychiatric services for residents exhibiting sexually inappropriate behaviors. Immediate Jeopardy was removed by 7/29/2021, but the facility remained out of compliance at a lower scope and severity.
Deficiencies (2)
Failure to provide adequate supervision to protect residents from sexual abuse, resulting in sexual assault of resident R#6 by R#17 and exposure of resident R#1 to sexually inappropriate behavior by R#16.
Failure to notify the State Survey Agency within the two-hour timeframe of alleged abuse incidents involving residents R#6 and R#1.
Report Facts
Resident census: 165
Staff education completion: 140
Total employees: 141
Residents referred for psychiatric services: 25
Residents referred for psychiatric services: 4
Residents referred for psychiatric services: 6
Residents referred for psychiatric services: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Director of Clinical Operations | Conducted in-services on Abuse & Neglect Prevention, Elder Justice Act and Resident Rights on 7/23/2021 | |
| Administrator | Informed of Immediate Jeopardy on 7/23/2021 and conducted in-service with Regional Director of Clinical Operations | |
| Director of Nursing (CDCO) | Involved in in-services and oversight of abuse prevention policies | |
| Social Services Director GG | Social Services Director | Interviewed regarding monitoring of residents with behaviors and education efforts |
| Social Services Coordinator UUU | Interviewed regarding education and referral processes | |
| Behavioral Health Therapist | Conducts weekly visits with residents for behavioral health services |
Inspection Report
Complaint Investigation
Census: 170
Deficiencies: 3
Date: Jul 23, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints alleging sexual abuse and failure to report incidents timely.
Complaint Details
Complaints GA00213908 and GA00214168 were substantiated with deficiencies cited. Complaints GA00212394, GA00212397, GA00213628, GA00213778, GA00214167, GA00215998, GA00215705, GA00214281, GA00214337, GA00215011, GA00215621, GA00215880, and GA00215751 were unsubstantiated.
Findings
The facility failed to protect residents from sexual abuse, resulting in one resident being sexually assaulted by another newly admitted resident. The facility also failed to timely notify the State Survey Agency within the required two-hour timeframe for two incidents of alleged sexual abuse. Additionally, the facility failed to adequately assess and monitor residents at risk for sexually inappropriate behaviors and did not implement psychiatric follow-up or interventions for a resident with a history of such behaviors.
Deficiencies (3)
Failure to provide adequate supervision to protect residents from sexual abuse, resulting in a resident being raped by another resident.
Failure to notify the State Survey Agency within the two-hour timeframe of alleged sexual abuse incidents.
Failure to assess and monitor residents at risk for sexually inappropriate behaviors and failure to implement psychiatric follow-up and interventions.
Report Facts
Resident census: 170
Deficiency count: 3
Report submission time: 6.5
Report submission time: 7.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LL | Certified Nursing Assistant | Found resident R#17 on top of R#6 during sexual assault incident |
| MM | Certified Nursing Assistant | Assisted in locating R#17 during sexual assault incident and provided witness statement |
| TT | Registered Nurse | Charge nurse during sexual assault incident involving R#6 and R#17 |
| VV | Licensed Practical Nurse / Unit Manager | Second floor Unit Manager during incident involving R#16 and R#1 |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 21, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00211057 and #GA00211407 in conjunction with a Focused Infection Control survey.
Complaint Details
Complaints #GA00211057 and #GA00211407 were investigated and found to be unsubstantiated.
Findings
The complaints were unsubstantiated and no regulatory violations were cited. The facility was found to be in compliance with 42 CFR §483.73 related to COVID-19 emergency preparedness.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 1, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00209212.
Complaint Details
Complaint #GA00209212 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 20, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00208711 and GA00208149.
Complaint Details
Complaints GA00208149 and GA00208711 were investigated and found to be unsubstantiated.
Findings
The complaints were unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 4, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints and to assess the facility's infection control practices related to COVID-19.
Complaint Details
Multiple complaints were investigated (GA00198643, GA00199640, GA200899, GA00202443, GA00202980, GA00204873, GA00204899, GA00205134, GA00205224, GA00206021, GA00206776, and GA00205152). All complaints were unsubstantiated.
Findings
The complaints investigated during the survey were unsubstantiated, and no deficiencies were found related to complaint #GA00205152. The infection control practices were reviewed via a desk review.
Report Facts
Complaint numbers investigated: 12
Inspection Report
Routine
Census: 142
Deficiencies: 0
Date: Aug 4, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with federal regulations and recommended practices related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices for COVID-19.
Inspection Report
Abbreviated Survey
Census: 140
Deficiencies: 0
Date: Jun 26, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted on June 25-26, 2020 by Ascellon on behalf of the Georgia Department of Community Health.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total census: 140
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 30, 2019
Visit Reason
A complaint survey was conducted on 5/30/2019 to investigate complaints #GA00195337 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint investigation for complaint #GA00195337; no deficiencies were found.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 20, 2019
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 20, 2019
Visit Reason
A complaint survey was conducted to investigate complaints GA00194665 and GA00193488 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
The survey was conducted in response to complaints GA00194665 and GA00193488; no deficiencies were found.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Follow-Up
Capacity: 168
Deficiencies: 4
Date: Feb 6, 2019
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies at the facility.
Findings
The facility failed to properly maintain rated doors, door latching devices, door self-closers, and corridor opening doors, which could place 168 residents at risk in the event of an emergency or fire. Specific deficiencies included damaged rated doors, missing or damaged self-closers, doors not creating smoke resistant seals, doors not latching, and transfer grills installed in corridor doors.
Deficiencies (4)
Facility failed to properly maintain facility rated doors and door latching devices, including damaged rated doors in multiple locations.
Facility failed to properly maintain door self-closers; self-closers were removed, damaged, or never installed in several rooms.
Facility failed to properly maintain doors protecting corridor openings; doors did not create smoke resistant seals and did not latch.
Facility failed to properly maintain corridor opening doors; transfer grills were installed in corridor doors in multiple administrative and staff areas.
Report Facts
Total licensed capacity: 168
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during the tour and interviews |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 4, 2019
Visit Reason
A follow-up to the Recertification survey of December 13, 2018 was conducted to verify correction of previously cited deficiencies.
Findings
The follow-up survey revealed that previously cited deficiencies were corrected.
Inspection Report
Complaint Investigation
Census: 168
Deficiencies: 2
Date: Dec 13, 2018
Visit Reason
The inspection was a standard survey conducted from December 10, 2018 through December 13, 2018, which included investigation of Complaint Intake Number GA #00193327 in conjunction with the standard survey.
Complaint Details
Complaint Intake Number GA #00193327 was investigated in conjunction with the standard survey. The complaint involved failure to implement restorative care plan interventions for resident #36.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, specifically failing to implement the care plan interventions for restorative services for one resident (R#36). The resident's right-hand splint, required to maintain strengthening and prevent contractures, was found unused and left on the floor for several days despite care plan orders and restorative nursing program requirements.
Deficiencies (2)
Failure to implement restorative care plan interventions for resident #36, specifically not applying the right-hand splint as ordered to maintain strengthening and prevent contractures.
Failure to provide appropriate care and services to maintain or improve resident #36's ability in activities of daily living, including restorative nursing for splinting and active range of motion.
Report Facts
Resident census: 168
Sampled residents: 33
Hours per day splint application: 6
Hours per day splint application: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Occupational Therapist | Interviewed regarding therapy referral and coordination with nursing for resident #36 |
| AA | Lead Restorative Certified Nursing Assistant | Interviewed regarding restorative nursing program and splint application for resident #36 |
| DD | Certified Nursing Assistant | Observed providing hygiene care to resident #36 without applying splint |
| ADON | Assistant Director of Nursing | Responsible for restorative program; interviewed about splint application and resident refusals |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Dec 13, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with nursing care requirements and restorative nursing services at Legacy Transitional Care & Rehabilitation.
Findings
The facility failed to provide nursing care according to the resident's restorative care plan, specifically failing to apply a prescribed right-hand splint for resident #36 as ordered. Observations revealed the splint was left on the floor for several days, and there was no documentation of splint application or refusals of care in the clinical record.
Deficiencies (1)
Failure to apply right-hand splint as ordered for resident #36, with the splint found on the floor for several days and no documentation of application or refusals.
Report Facts
BIMS score: 13
BIMS score: 15
Splint application hours: 6
Splint application hours: 8
Date of admission: Oct 1, 2017
Restorative nursing documentation period: 189
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Occupational Therapist | Interviewed regarding therapy referral and coordination of resident care plan |
| AA | Lead Restorative Certified Nursing Assistant | Interviewed regarding restorative nursing program roster and splint application |
| DD | Certified Nursing Assistant | Observed providing hygiene care and assisting resident with dressing |
| ADON | Assistant Director of Nursing | Responsible for restorative program and ensuring assistive devices are applied |
Inspection Report
Life Safety
Census: 68
Capacity: 186
Deficiencies: 14
Date: Dec 10, 2018
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with Life Safety Code requirements, including deficiencies in maintaining rated doors, exit and emergency lighting, fire alarm system, sprinkler system, corridor doors, smoke barriers, electrical systems, fire drills, door inspections, space heater use, generator maintenance, and oxygen cylinder storage.
Deficiencies (14)
Facility failed to properly maintain facility rated doors and door latching devices.
Facility failed to properly maintain exit lighting; exit lighting not tested monthly for 30 seconds and annually for 90 minutes.
Facility failed to properly maintain emergency lighting; emergency lighting not tested monthly for 30 seconds and annually for 90 minutes.
Facility failed to properly maintain door self-closers; self-closers removed, damaged or never installed in multiple mechanical and utility rooms.
Facility failed to properly maintain fire alarm system; issues with breaker identification, breaker color/lock, battery marking, and circuit identification.
Facility failed to properly maintain fire sprinkler system; sprinkler heads loaded with dust and one installed outside its listing.
Facility failed to properly maintain corridor doors; doors not creating smoke resistant seals, doors not latching, and transfer grills installed in corridor doors.
Facility failed to properly maintain rated walls and ceilings; improperly and unprotected penetrations in mechanical rooms, storage rooms, stairs, and phone room.
Facility failed to properly maintain electrical systems; damaged flexible power cord and missing knockout in junction box.
Facility failed to conduct quarterly fire drills on all shifts; missing drills on 3rd shift 1st quarter and 2nd shift 3rd and 4th quarters.
Facility failed to properly maintain corridor rated doors; no routine inspections of rated doors.
Facility failed to properly control use of portable space heaters; non-compliant space heaters in main lobby and office.
Facility failed to properly maintain emergency generator; missing monthly load runs for March and August 2018 and no annual load bank test.
Facility failed to properly secure oxygen cylinders; five cylinders unsecured in second floor oxygen storage room.
Report Facts
Residents at risk: 168
Oxygen cylinders unsecured: 5
Certified beds: 186
Census: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during facility tour and interviews. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 7, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00191283, GA00191315, GA00192628, and GA00190081.
Complaint Details
Complaints GA00191283, GA00191315, GA00192628, and GA00190081 were investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaints investigated during the survey were unsubstantiated and no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 21, 2018
Visit Reason
A complaint survey was conducted to investigate complaints #GA00190801 and determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint #GA00190801 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 1, 2018
Visit Reason
An unannounced, abbreviated survey was conducted to investigate a complaint alleging improper medication administration and unclean facility conditions.
Complaint Details
Complaint# GA00188734 alleging improper medication administration and unclean facility conditions was investigated and found unsubstantiated.
Findings
The allegations of improper medication administration and the facility not being kept clean were found to be unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 24, 2018
Visit Reason
A complaint survey was conducted to investigate complaints #GA00187310 and #GA00187867 to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaints #GA00187310 and #GA00187867 were investigated and found to be unsubstantiated as no deficiencies were cited.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 16, 2018
Visit Reason
A revisit survey was conducted on 3/16/18 to verify correction of deficiencies cited in the 1/12/18 Recertification Survey. Additionally, a complaint investigation (GA00186388) was conducted in conjunction with this revisit.
Complaint Details
Complaint GA00186388 was investigated and found substantiated with no deficiencies.
Findings
All deficiencies cited in the 1/12/18 Recertification Survey were found to be corrected. The complaint investigation was substantiated but found no deficiencies.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 16, 2018
Visit Reason
A revisit survey was conducted on 3/16/18 to verify correction of deficiencies cited in the 1/12/18 Recertification Survey and to investigate Complaint Intake Number GA00186388.
Complaint Details
Complaint Intake Number GA00186388 was investigated and found to be substantiated with no deficiencies.
Findings
All deficiencies cited in the 1/12/18 Recertification Survey were found to be corrected. The complaint investigation was substantiated but resulted in no deficiencies.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 2, 2018
Visit Reason
A follow-up survey was conducted to verify correction of previously cited survey deficiencies.
Findings
The follow-up survey noted that all previously cited survey tags have been corrected.
Inspection Report
Life Safety
Census: 164
Capacity: 186
Deficiencies: 1
Date: Jan 9, 2018
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition.
Findings
The facility was found not in substantial compliance due to failure to have the sprinkler system annually tested within the required 12-month calendar year. The last inspection was on 2016-10-16, making it almost 2.5 months overdue, potentially placing residents at risk if the sprinkler system fails to activate.
Deficiencies (1)
Failure to have the sprinkler system annually tested within the 12 month calendar year; last inspection was 10-16-2016, overdue by almost 2.5 months.
Report Facts
Census: 164
Total Capacity: 186
Days overdue for sprinkler inspection: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding sprinkler system inspection during facility tour on 2018-01-01 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 2, 2017
Visit Reason
The inspection was conducted to investigate Complaint #GA00182549 to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00182549 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation completed on 12/20/2017.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 10, 2017
Visit Reason
The inspection was conducted to investigate complaint GA00181708.
Complaint Details
Complaint GA00181708 was investigated and found to have no health deficiencies.
Findings
No health deficiencies were cited during the complaint survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 8, 2017
Visit Reason
An abbreviated survey was conducted to investigate complaint GA00180561, initiated on October 7, 2017 and concluded on October 8, 2017.
Complaint Details
Complaint GA00180561 was investigated; one of four allegations was substantiated but no deficient practice was found.
Findings
One of four allegations was substantiated; however, no deficient practice was cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 30, 2017
Visit Reason
A complaint survey was conducted on 9/29/17 - 9/30/17 to investigate complaint #GA00180239.
Complaint Details
Complaint #GA00180239 was investigated and found to have no health deficiencies.
Findings
No health deficiencies were cited during the complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 29, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00180239 and determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00180239 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey at Legacy Transitional Care and Rehabilitation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 23, 2017
Visit Reason
The inspection was conducted to investigate Complaint #GA00179678 to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00179678 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 18, 2017
Visit Reason
An unannounced complaint survey was conducted to investigate Complaint # GA0017735 and determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint # GA0017735 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 7, 2017
Visit Reason
A revisit was conducted on 2/6/17 to the recertification survey conducted on December 12-15, 2016, to verify substantial compliance with Medicare regulations.
Findings
The facility was found to be in substantial compliance with Medicare regulations at 42CFR48 Subpart B-Requirements for Long Term Care Facilities, as alleged in their Plan of Correction effective on 1/29/17.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 6, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected.
Inspection Report
Life Safety
Census: 173
Capacity: 186
Deficiencies: 7
Date: Dec 13, 2016
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failure to maintain door closers on combustible storage rooms, missing protective caps on fire extinguishment spray heads, sprinkler heads loaded with dust, resident doors not closing and latching properly, smoke barriers and doors failing to resist smoke passage, and electrical safety hazards such as open circuits and power strips on the floor.
Deficiencies (7)
Failed to provide and maintain door closers in all combustible storage rooms/spaces over 50 Sq. Ft.
Failed to assure extinguishment effectiveness in food cooking area due to missing protective cap on fire extinguishment spray head.
Failed to maintain sprinkler system coverage; sprinkler heads loaded with dust that may hamper activation.
Resident doors would not close completely and properly latch in three rooms.
Smoke barriers above ceilings could not limit or resist passage of smoke in multiple locations.
Failed to assure compartmentation with smoke doors; smoke door at Room #405 would not close completely.
Electrical circuits open to danger; missing protective covers on electrical panels and power strips found on the floor.
Report Facts
Residents at risk due to door closer deficiency: 61
Staff at risk due to cooking area extinguishment deficiency: 6
Residents at risk due to sprinkler system deficiency: 61
Residents at risk due to door operation deficiency: 32
Residents at risk due to smoke barrier deficiency: 32
Residents at risk due to smoke door deficiency: 32
Residents at risk due to electrical safety deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings at time of discovery for multiple deficiencies |
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