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Inspection visit

Routine inspection

LEGACY SENIOR CARE IILicense 3459200841 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection utilizing the CARE tool. LPA met with staff and explained the purpose of the visit. Administrator informed LPA on the phone she was an hour away and unable to make it. LPA observed three residents in care with one resident on hospice services. LPA was informed two residents are at the hospital for evaluation. Facility census is compliance to license. Today's visit, LPA and staff conducted a tour of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: four residents bedrooms, laundry room, staff room, kitchen and the common areas. LPA observed the common area to have the mandated compliance posters posted. LPA observed fire extinguisher to be recently serviced on November 5, 2024. Facility temperature was observed at a comfortable 72*F. LPA observed facility to have ample perishable and nonperishable food supply. LPA observed carbon monoxide detectors to be working and in good condition. Sharps are stored in staff room which was observed to be locked. LPA observed laundry room to be locked. Medications are stored in closet, locked and secured. Emergency Disaster Plan was observed to be reviewed and updated in 2024, pending review for 2025. File review conducted for five out of five residents in care. LPA observed R1 and R2's medical assessment present with no documentation of tuberculosis testing. As a result of today's visit, deficiencies cited. Exit interview and a copy of report and appeal rights was emailed.

Citations

2 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.

  • 87458(c)(1)(A)Type B

    Based on file review, the licensee did not comply with the section cited above as two out of five residents did not have tuberculosis testing documented on LIC602 which poses a potential risk for residents in care.

  • 87211(a)(1)(D)Type B

    87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.This requirement is not met as evidenced by: Based on file review, Licensee did not comply as LPA was made aware that R1 and R2 are at the hospital but no incident reports observed which poses a potential risk for residents in care.

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FAQ · About this visit

Common questions about this visit

What happened during the April 25, 2025 inspection of LEGACY SENIOR CARE II?

This was a inspection inspection of LEGACY SENIOR CARE II on April 25, 2025. 1 citation were issued: 1 Type B.

Were any citations issued to LEGACY SENIOR CARE II on April 25, 2025?

Yes, 1 citation was issued (0 Type A, 1 Type B). The first citation was for: "Based on file review, the licensee did not comply with the section cited above as two out of five residents did not have..."

What type of inspection was this?

This was a inspection inspection. inspection inspections are conducted by CCLD as part of their licensing oversight.

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.