Legacy Post Acute Care

• Star rating

  The CMS staffing star rating changed from 4 of 5 to 5 of 5.

• Star rating

  The CMS health inspection star rating changed from 5 of 5 to 4 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 5 of 5.

CMS lists this as a complaint inspection.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on April 24, 2026.

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CMS lists this as a complaint inspection.

• Citation F0573. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

  CMS lists it as corrected on January 3, 2026.

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• Star rating

  The CMS quality measures star rating changed from 5 of 5 to 4 of 5.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 3 of 5.

CMS lists this as a standard inspection.

• Citation F0578. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

  CMS lists it as corrected on February 6, 2025.

• Citation F0640. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

  CMS lists it as corrected on February 6, 2025.

• Citation F0655. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

  CMS lists it as corrected on February 6, 2025.

• Citation F0759. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure medication error rates are not 5 percent or greater.

  CMS lists it as corrected on February 6, 2025.

  CMS has cited this home for F0759 2 times since 2019.

• Citation F0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  CMS lists it as corrected on February 6, 2025.

  CMS has cited this home for F0761 2 times since 2022.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on February 6, 2025.

  CMS has cited this home for F0880 2 times since 2019.

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CMS lists this as a standard inspection.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on January 31, 2025.

  CMS has cited this home for K0918 2 times since 2022.

• Citation K0353. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on January 27, 2025.

  CMS has cited this home for K0353 2 times since 2022.

• Citation K0342. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

  CMS lists it as corrected on January 31, 2025.

• Citation K0712. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on January 27, 2025.

  CMS has cited this home for K0712 2 times since 2022.

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• Star rating

  The CMS staffing star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS health inspection star rating changed from 4 of 5 to 5 of 5.

CMS lists this as a standard inspection.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on November 14, 2022.

• Citation F0761. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  CMS lists it as corrected on November 14, 2022.

• Citation F0803. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

  CMS lists it as corrected on November 14, 2022.

  CMS has cited this home for F0803 2 times since 2019.

• Citation F0690. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  CMS lists it as corrected on November 14, 2022.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on November 14, 2022.

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CMS lists this as a standard inspection.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on November 29, 2022.

• Citation K0293. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have properly located and lighted "Exit" signs.

  CMS lists it as corrected on November 29, 2022.

• Citation K0353. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on November 29, 2022.

• Citation K0355. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Properly select, install, inspect, or maintain portable fire extinguishes.

  CMS lists it as corrected on November 29, 2022.

• Citation E0030. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: List the names and contact information of those in the facility.

  CMS lists it as corrected on November 29, 2022.

• Citation E0031. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide emergency officials' contact information.

  CMS lists it as corrected on November 29, 2022.

  CMS has cited this home for E0031 2 times since 2019.

• Citation E0039. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Conduct testing and exercise requirements.

  CMS lists it as corrected on November 29, 2022.

  CMS has cited this home for E0039 2 times since 2019.

• Citation K0324. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on November 29, 2022.

• Citation K0346. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Follow proper procedures when the fire alarm was out of service for more than 4 hours.

  CMS lists it as corrected on November 29, 2022.

• Citation K0354. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

  CMS lists it as corrected on November 29, 2022.

• Citation K0712. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on November 29, 2022.

• Citation K0921. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that testing and maintenance of electrical equipment is performed.

  CMS lists it as corrected on November 29, 2022.

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CMS lists this as a standard inspection.

• Citation F0803. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

  CMS lists it as corrected on September 16, 2019.

• Citation F0755. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on September 16, 2019.

• Citation F0759. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure medication error rates are not 5 percent or greater.

  CMS lists it as corrected on September 16, 2019.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on September 16, 2019.

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CMS lists this as a standard inspection.

• Citation E0009. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Include a process for Emergency Preparedness collaboration.

  CMS lists it as corrected on October 13, 2019.

• Citation E0031. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide emergency officials' contact information.

  CMS lists it as corrected on October 13, 2019.

• Citation E0032. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide primary/alternate means for communication.

  CMS lists it as corrected on October 13, 2019.

• Citation E0039. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Conduct testing and exercise requirements.

  CMS lists it as corrected on October 13, 2019.

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