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Inspection visit

Complaint

LEGACY SENIOR CARELicense 3459200632 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

Staff are not preventing a resident from wandering away from facility Records reviewed indicated that Resident R1 was unable to leave the facility unattended. R1 enjoyed taking walks outdoors and would be accompanied by a staff member. On 03/26/2026, R1 turned off the front door alarm, which staff were aware R1 was able to do, and walked out the front door to stand in the driveway. Staff were only alerted that R1 left the facility when a neighbor saw R1 standing in the driveway and brought R1 back inside. Interviews conducted indicated that staff were “on-call” and sleeping as facility does not require wake staff at night. Staff S1 was made aware of R1 leaving the premises when a neighbor brought R1 back inside the facility early morning on 3/26/2026. Therefore, the allegation staff are not preventing a resident from wandering away from facility is substantiated. Staff are not adequately supervising resident in care Interviews conducted with administrator and staff member S1 indicated that Resident R1 was a wandering risk. Staff would take R1 on walks around the neighborhood but sometimes R1 would try to leave the facility unassisted by turning off the front door alarm and walking outside. Staff were aware the R1 had wandering tendencies and knew that R1 had attempted to elope prior to the incident on 3/26/2026. Records reviewed indicated that R1 was unable to leave the facility unsupervised. Therefore, the allegation staff are not adequately supervising resident in care is substantiated. Based on the information obtained for the allegations above, the allegations are SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Exit interview conducted with Executive Director and a copy of the report and appeal rights was provided.

Citations

3 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87465(a)(4)Type A

    Assist residents with self-administered medication

    87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self administered medications as needed. This requirement is not met as evidenced by: Based on interviews and record review, staff are not providing medications as ordered by physician which poses an immediate health, safety or personal rights risk to persons in care.

  • 87463(a)(b)Type A

    87463 Reappraisals (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident This requirement is not met as evidenced by: Based on interviews and record review the licensee did not meet the needs of resident which poses an immediate health, safety or personal rights risk to persons in care.

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  • 87461(a)(b)Type A

    87461 Mental Condition (a) The facility shall determine the amount of supervision necessary by assessing the mental status of the prospective resident to determine if the individual: (1) tends to wander; (2) is confused or forgetful; This requirement is not met as evidenced by: Based on interviewed and record review the licensee did not provide sufficient supervision which poses an immediate health , safety or personal rights risk to persons in care.

FAQ · About this visit

Common questions about this visit

What happened during the May 13, 2026 inspection of LEGACY SENIOR CARE?

This was a complaint inspection of LEGACY SENIOR CARE on May 13, 2026. 2 citations were issued: 2 Type A (serious).

Were any citations issued to LEGACY SENIOR CARE on May 13, 2026?

Yes, 2 citations were issued (2 Type A, 0 Type B). The first citation was for: "87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each f..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.