Our Legacy Llc

Based on observation, interview, and record review, the licensee did not comply with the section cited above in two out of seven client files where a health screening was missing, which poses a potential health, safety or personal rights risk to persons in care.

Based on observation and interview, the licensee did not comply with the section cited above in one out of one kitchens where cleaning supplies were not locked and inaccessible to clients in care, which posed a potential health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above in one incident which required an unusual incident report to be submitted, which poses a potential health, safety or personal rights risk to persons in care.

Based on observation and interview, the licensee did not comply with the section cited above in two out of five bedrooms that had broken drawers, which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above with (1) resident who passed away and no report was received by the regional office. LPA requested the report during the time of the visit, however the licensee did not have the date of the resident's passing and LPA obtained the date from the medical provider of R5. This poses a potential health, safety or personal rights risk to persons in care.

Based on interview and record review, the licensee did not comply with the section cited above with S2 who did not have a fingerprint clearance which poses an immediate health, safety or personal rights risk to persons in care.

Based on interview, record review, the licensee did not comply with the section cited with (1) unassociated staff who worked at the facility for (1) month and (1) uncleared staff who worked at the facility for (6) months which poses an immediate health, safety or personal rights risk to persons in care.

Based on interview and record review, the licensee did not comply with the section cited above with the administration, and (6) staff records that were incomplete which poses a potential health, safety or personal rights risk to persons in care.

Based on interview, record review, the licensee did not comply with the section cited above with all resident records that were incompleted which poses a potential health, safety or personal rights risk to persons in care.

Based on interview and record review, the licensee did not comply with the section cited above with S1 who was not associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, interview, record review, the licensee did not comply with the section cited above with staff schedule showing staff that are not associated to the facility and with (1) staff present during the visit and LPA observed residents need for supervision as (1) resident wandered while staff was changing another resident out of sight which poses an immediate health, safety or personal rights risk to persons in care.

Based on interview and record review, the licensee did not comply with the section cited above in staff files that did not contain staff training including orientation, medication, and annual 40 hours training which poses a potential health, safety or personal rights risk to persons in care.

Based on interview and record review, the licensee did not comply with the section cited above with last fire drill conducted 11/25/2024 which was past the quarterly requirement which poses a potential health, safety or personal rights risk to persons in care.

Based on interview and record review, the licensee did not comply with the section cited above with (3) resident that did not have a record of care which poses a potential health, safety or personal rights risk to persons in care.

Based on interview and record review, the licensee did not comply with the section cited above with (1) resident that was found to be bedridden. The facility does not have a fire clearance for this resident which poses a potential health, safety or personal rights risk to persons in care.