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Inspection visit

Incident investigation

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

Inspector’s narrative

What the inspector wrote

Licensing Program Analysts (LPAs) Cassie Yang and Kevin Mknelly arrived at the facility to conduct a case management visit regarding an incident that LPAs were made aware of during LPAs' visit. LPA met with Administrator and explained the purpose of the visit. Upon LPAs' arrival, LPAs were informed that today's census was five (5) residents in care as resident (R1) had recently passed away in the month of December 2025. File review was conducted and observed that R1 was not on hospice services. Administrator stated death report was submitted but to the wrong regional office. LPA was provided a copy of R1's death report. File review revealed R1 passed away December 18, 2025 but death report was not submitted to Licensing until December 29, 2025. LPAs and Administrator discussed the importance of submitting death reports in a timely manner within the seven days of occurrence. At this time, this matter remains under review by the Department. Deficiencies cited. As this is a repeated violation, an additional $250 civil penalty has been assessed. Exit interview conducted and a copy of report and appeal rights provided.

Citations

1 citation 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.

  • 87211(a)(1)(A)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. (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. Based on file review and interview, Licensee failed to comply as death report was not submited to Licensing until 11 days after occurrence, 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 January 8, 2026 inspection of LEGACY SENIOR CARE II?

This was a other inspection of LEGACY SENIOR CARE II on January 8, 2026. 1 citation were issued: 1 Type B.

Were any citations issued to LEGACY SENIOR CARE II on January 8, 2026?

Yes, 1 citation was issued (0 Type A, 1 Type B). The first citation was for: "87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may ..."

What type of inspection was this?

This was a other inspection. other 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.