Inspection Reports for Legacy Transitional Care & Rehabilitation

This document is a Statement of Deficiencies and Plan of Correction for Legacy Transitional Care & Rehabilitation following a survey completed on June 4, 2025.

The report contains initial comments but does not provide specific details on deficiencies or findings.

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.

All deficiencies cited during the April 11, 2025 recertification survey were found to be corrected. The complaint investigation was unsubstantiated with no deficiencies cited.

Complaint Intake Number GA00254999 was investigated and found to be unsubstantiated with no deficiencies cited.

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.

All deficiencies cited during the April 11, 2025 recertification survey were found to be corrected. The complaint investigation was unsubstantiated with no deficiencies cited.

Complaint Intake Number GA00254999 was investigated and found to be unsubstantiated with no deficiencies cited.

A follow-up survey was conducted to verify correction of previously cited survey deficiencies.

The follow-up survey noted that all previously cited survey tags had been corrected.

An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00255055 at Legacy Transitional Care and Rehabilitation.

The complaint GA00255055 was unsubstantiated and no deficiencies were cited during the survey.

Complaint GA00255055 was investigated and found to be unsubstantiated with no deficiencies cited.

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.

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.

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.

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.

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.

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.

The survey included investigation of Complaint Intake Numbers GA00253884, GA00254333, GA00254456, and GA00254525 in conjunction with the standard survey.

An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00252845, GA00252949, GA00253330, and GA00253558.

The complaints investigated were unsubstantiated, and no regulatory violations were cited during the survey.

Complaints GA00252845, GA00252949, GA00253330, and GA00253558 were investigated and found to be unsubstantiated.

The document is a Statement of Deficiencies and Plan of Correction for Legacy Transitional Care & Rehabilitation, indicating a regulatory inspection was conducted.

The report contains initial comments but does not provide specific details or findings of deficiencies.

A revisit survey was conducted to verify correction of deficiencies cited in the prior recertification with complaint survey conducted on 2024-11-08.

All deficiencies cited as a result of the 11/8/2024 recertification with complaint survey were found to be corrected.

The revisit survey was related to a prior complaint survey conducted on 11/8/2024.

A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.

All previously cited survey tags have been corrected as noted by the surveyor.

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.

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.

Complaint Intake Number GA00251918 was investigated in conjunction with the standard survey and was substantiated without deficiencies.

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.

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.

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.

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.

A complaint survey was initiated on August 1, 2024, to investigate multiple complaints against the facility and concluded on August 30, 2024.

Three complaints were unsubstantiated, and one complaint was substantiated but with no regulatory violations cited.

Complaints GA00248222, GA00249058, and GA00249146 were unsubstantiated. Complaint GA00249114 was substantiated with no regulatory violations cited.

The document is a statement of deficiencies and plan of correction for Legacy Transitional Care & Rehabilitation, indicating a regulatory inspection was conducted.

The report contains initial comments but does not provide specific details on deficiencies or findings.

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.

All deficiencies cited in the prior 5/16/2024 Recertification survey and Complaint Investigation were found to be corrected. The complaint was unsubstantiated.

Complaint Intake Number GA00246980 was investigated and found to be unsubstantiated.

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.

All deficiencies cited in the prior recertification survey and complaint investigation were found to be corrected. The complaint was unsubstantiated.

Complaint Intake Number GA00246980 was investigated and found to be unsubstantiated.

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.

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.

Complaint Intake Number GA00245101 was substantiated without deficiencies. Complaint Intake Number GA00245097 was substantiated with deficiencies related to the standard survey findings.

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.

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.

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.

The facility was found to be in substantial compliance with the Emergency Preparedness Program requirements and Life Safety Code standards during the survey.

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.

The facility was found to be in substantial compliance with the Emergency Preparedness Program requirements and Life Safety Code standards during the survey.

This document is a Statement of Deficiencies and Plan of Correction for Legacy Transitional Care & Rehabilitation following a survey completed on 05/07/2024.

The document contains initial comments but does not provide specific details on deficiencies or findings.

A Revisit Survey was conducted to verify correction of deficiencies cited during the 3/11/2024 Complaint Survey.

All deficiencies cited as a result of the 3/11/2024 Complaint Survey were found to be corrected.

The visit was a follow-up to a complaint survey conducted on 3/11/2024; all cited deficiencies were corrected.

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.

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.

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.

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.

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.

An abbreviated/partial extended survey was conducted to investigate complaints GA00242437, GA00242435, GA00242315, and GA00242374.

No deficiencies were cited related to the complaints investigated during this survey.

The survey investigated complaints GA00242437, GA00242435, GA00242315, and GA00242374; no deficiencies were found related to these complaints.

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.

The report contains initial comments but does not provide specific details on deficiencies or findings.

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.

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.

Complaint intake GA00240222 was unsubstantiated with no deficiencies cited; GA00241005 was substantiated without deficiencies cited.

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.

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.

Complaint Intake Number GA00241005 was substantiated with no deficiencies; Complaint Intake Number GA00240222 was unsubstantiated.

A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.

The surveyor noted that all previously cited deficiencies had been corrected during the follow-up survey.

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.

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.

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.

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.

Complaint Intake numbers GA00239112 and GA00239469 were unsubstantiated. Complaint Intake number GA00238638 was substantiated with deficiency cited.

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.

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.

The document is a Statement of Deficiencies and Plan of Correction for Legacy Transitional Care & Rehabilitation, indicating a regulatory inspection was conducted.

No deficiencies or findings are listed in the report; the statement of deficiencies section is blank.

A revisit survey was conducted to verify correction of deficiencies cited during the August 10, 2023 Complaint Survey.

All deficiencies cited as a result of the August 10, 2023 Complaint Survey were found to be corrected.

The visit was a follow-up to a complaint survey conducted on August 10, 2023; all cited deficiencies were corrected.

This document is a Statement of Deficiencies and Plan of Correction for Legacy Transitional Care & Rehabilitation following a survey completed on August 10, 2023.

The report contains initial comments but does not specify any detailed deficiencies or findings.

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.

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.

Complaint intake numbers GA00235947, GA00236150, and GA00236501 were investigated in conjunction with this revisit survey. Deficient practice was identified related to the complaint investigation.

A Licensure Survey was conducted from August 8, 2023 through August 10, 2023 to assess compliance with licensure requirements.

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.

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.

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.

The survey was complaint-related, investigating complaints GA00235947, GA00236150, and GA00236501. The facility was found noncompliant related to the complaint survey.

The facility was reviewed for compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network during a seven-day period.

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.

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.

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.

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.

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.

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.

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.

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.

A revisit survey was conducted to verify correction of deficiencies cited during the September 24, 2022, Recertification and Complaint Investigation survey.

All deficiencies cited as a result of the September 24, 2022, Recertification in conjunction with a Complaint Investigation survey were found to be corrected.

The revisit was related to a prior Complaint Investigation survey conducted on September 24, 2022.

A revisit survey was conducted to verify correction of deficiencies cited during the September 24, 2022, Recertification in conjunction with a Complaint Investigation survey.

All deficiencies cited as a result of the September 24, 2022 survey were found to be corrected.

The revisit survey followed a Complaint Investigation survey conducted on September 24, 2022.

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.

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.

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.

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.

The survey included investigation of multiple complaint intake numbers, some of which were substantiated with deficiencies related to infection control and resident care.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 standard.

The facility was found to be in compliance with the Emergency Preparedness Program requirements and Life Safety Code standards during the survey.

This document is a Statement of Deficiencies and Plan of Correction for Legacy Transitional Care & Rehabilitation following a survey completed on October 14, 2021.

The document contains initial comments but does not provide specific details on deficiencies or findings.

A Revisit Survey was conducted to verify correction of deficiencies cited in the July 23, 2021 Complaint Survey.

All deficiencies cited as a result of the July 23, 2021 Complaint Survey were found to be corrected.

This revisit survey followed a complaint survey conducted on July 23, 2021, and confirmed all cited deficiencies were corrected.

An Abbreviated Survey was conducted to investigate complaints #GA00216440 and #GA00216406.

The complaints #GA00216440 and #GA00216406 were substantiated with no deficiencies found during the survey.

Complaints #GA00216440 and #GA00216406 were substantiated with no deficiencies.

The visit was conducted as a licensure survey for the facility.

No deficiencies were identified during the licensure survey conducted from 7/20/2021 through 7/23/2021.

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.

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.

Complaint intake numbers GA00216440 and GA00216406 were investigated and substantiated with no deficiencies.

An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints alleging sexual abuse and failure to report incidents timely.

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.

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.

An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00211057 and #GA00211407 in conjunction with a Focused Infection Control survey.

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.

Complaints #GA00211057 and #GA00211407 were investigated and found to be unsubstantiated.

An abbreviated/partial extended survey was conducted to investigate complaint #GA00209212.

The complaint was unsubstantiated and no regulatory violations were cited during the survey.

Complaint #GA00209212 was investigated and found to be unsubstantiated.

An abbreviated/partial extended survey was conducted to investigate complaints GA00208711 and GA00208149.

The complaints were unsubstantiated and no regulatory violations were cited during the survey.

Complaints GA00208149 and GA00208711 were investigated and found to be unsubstantiated.

An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints and to assess the facility's infection control practices related to COVID-19.

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.

Multiple complaints were investigated (GA00198643, GA00199640, GA200899, GA00202443, GA00202980, GA00204873, GA00204899, GA00205134, GA00205224, GA00206021, GA00206776, and GA00205152). All complaints were unsubstantiated.

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.

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.

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.

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.

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.

No deficiencies were cited during the complaint investigation survey.

Complaint investigation for complaint #GA00195337; no deficiencies were found.

A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.

The surveyor noted that all previously cited deficiencies had been corrected during the follow-up survey.

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.

No deficiencies were cited during the complaint investigation survey.

The survey was conducted in response to complaints GA00194665 and GA00193488; no deficiencies were found.

A Follow-Up Survey was conducted to verify correction of previously cited deficiencies at the facility.

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.

A follow-up to the Recertification survey of December 13, 2018 was conducted to verify correction of previously cited deficiencies.

The follow-up survey revealed that previously cited deficiencies were corrected.

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.

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.

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.

The inspection was conducted as an annual survey to assess compliance with nursing care requirements and restorative nursing services at Legacy Transitional Care & Rehabilitation.

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.

Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code 2012 edition.

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.

An abbreviated/partial extended survey was conducted to investigate complaints GA00191283, GA00191315, GA00192628, and GA00190081.

The complaints investigated during the survey were unsubstantiated and no deficiencies were found.

Complaints GA00191283, GA00191315, GA00192628, and GA00190081 were investigated and found to be unsubstantiated with no deficiencies.

A complaint survey was conducted to investigate complaints #GA00190801 and determine compliance with Federal and State Long Term Care Requirements.

No deficiencies were cited during the complaint survey.

Complaint #GA00190801 was investigated and found to have no deficiencies.

An unannounced, abbreviated survey was conducted to investigate a complaint alleging improper medication administration and unclean facility conditions.

The allegations of improper medication administration and the facility not being kept clean were found to be unsubstantiated.

Complaint# GA00188734 alleging improper medication administration and unclean facility conditions was investigated and found unsubstantiated.

A complaint survey was conducted to investigate complaints #GA00187310 and #GA00187867 to determine compliance with Federal and State Long Term Care Requirements.

No deficiencies were cited during the complaint survey.

Complaints #GA00187310 and #GA00187867 were investigated and found to be unsubstantiated as no deficiencies were cited.

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.

All deficiencies cited in the 1/12/18 Recertification Survey were found to be corrected. The complaint investigation was substantiated but found no deficiencies.

Complaint GA00186388 was investigated and found substantiated with no deficiencies.

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.

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.

Complaint Intake Number GA00186388 was investigated and found to be substantiated with no deficiencies.

A follow-up survey was conducted to verify correction of previously cited survey deficiencies.

The follow-up survey noted that all previously cited survey tags have been corrected.

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.

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.

The inspection was conducted to investigate Complaint #GA00182549 to determine compliance with Federal and State Long Term Care regulations.

The complaint was unsubstantiated and no deficiencies were cited during the investigation completed on 12/20/2017.

Complaint #GA00182549 was investigated and found to be unsubstantiated with no deficiencies cited.

The inspection was conducted to investigate complaint GA00181708.

No health deficiencies were cited during the complaint survey.

Complaint GA00181708 was investigated and found to have no health deficiencies.

An abbreviated survey was conducted to investigate complaint GA00180561, initiated on October 7, 2017 and concluded on October 8, 2017.

One of four allegations was substantiated; however, no deficient practice was cited.

Complaint GA00180561 was investigated; one of four allegations was substantiated but no deficient practice was found.

A complaint survey was conducted on 9/29/17 - 9/30/17 to investigate complaint #GA00180239.

No health deficiencies were cited during the complaint investigation.

Complaint #GA00180239 was investigated and found to have no health deficiencies.

The inspection was conducted to investigate complaint #GA00180239 and determine compliance with Federal and State Long Term Care regulations.

No deficiencies were cited during the complaint survey at Legacy Transitional Care and Rehabilitation.

Complaint #GA00180239 was investigated and found to have no deficiencies.

The inspection was conducted to investigate Complaint #GA00179678 to determine compliance with Federal and State Long Term Care regulations.

The complaint was found to be unsubstantiated and no deficiencies were cited during the survey.

Complaint #GA00179678 was investigated and found to be unsubstantiated with no deficiencies cited.

An unannounced complaint survey was conducted to investigate Complaint # GA0017735 and determine compliance with Federal and State Long Term Care Requirements.

No deficiencies were cited during the complaint investigation survey.

Complaint # GA0017735 was investigated and found to have no deficiencies.

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.

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.

A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.

The surveyor noted that all previously cited survey tags have been corrected.

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.

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.