Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Legacy Heights Nursing And Rehab, Llc during CMS and state inspections, most recent first.
Ice Machine Not Kept Clean: A Dietary Aide observed tan and gray debris inside an ice machine, and the substance was described as looking like dirt or mold. Staff gave conflicting accounts of how often the machine was cleaned, with Housekeeping/Laundry stating it was cleaned multiple times weekly and the MD stating it was cleaned monthly when mechanical components were checked. The Administrator stated the ice from the machine was used for residents.
The facility failed to ensure proper food storage, cleanliness, and hygiene practices in the kitchen, with observations of uncovered and undated food items, buildup of grease and residue, poor kitchen maintenance, and dietary staff not following hand hygiene protocols. Expired food items were also found, posing a potential risk for foodborne illness among the 82 residents receiving meals from the kitchen.
The facility failed to ensure proper security and storage of medications, including controlled substances like Lorazepam. A surveyor observed an unlocked and unattended medication cart and an emergency kit containing Lorazepam that was not in a locked and affixed container. The facility lacked a Medication Storage Policy, as confirmed by the DON and ADON.
The facility failed to serve meals according to the planned menu, providing only 0.5 cups of pureed pimento cheese sandwich instead of the required 1 cup to residents on pureed diets. This was confirmed by a dietary employee who admitted to using the incorrect spoon size and serving only one scoop.
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency, posing a risk to residents requiring pureed diets. Observations revealed gritty pureed sausage and lumpy pureed lasagna with intact noodles, affecting seven residents.
The facility failed to ensure that one of three shower rooms was clean. A brown substance, identified as bowel movement, was observed smeared on the floor in the bathroom on the Medicare Hall. The DON and Administrator confirmed that the shower room should be cleaned after use and between residents, and that soils should be cleaned after every shower and deep cleaned at the end of the day.
A resident with acute systolic heart failure was discharged with another resident's medication, which was not documented on the discharge summary. The LPN did not verify the medications, assuming the night shift had done so. The caregiver reported the error, but the Administrator did not conduct an in-service for the nurses involved.
A resident with Acute systolic heart failure was discharged with another resident's medication due to a failure in verifying medications against physician orders. The LPN responsible did not check the medications, and the Administrator did not provide an in-service for the nurses involved.
Ice Machine Not Kept Clean
Penalty
Summary
The facility failed to ensure that an ice machine was maintained in a clean condition. During an observation on 07/31/2025 at 12:15 PM, a Dietary Aide used a white paper towel to wipe the interior of the ice machine, and an unknown tan and gray substance transferred to the towel. The Dietary Aide stated the substance should not be there and said it looked like dirt and that the ice machine should be cleaned with vinegar. The Housekeeping/Laundry Supervisor observed the towel with the debris and reported that the substance looked like mold. During interviews, the Administrator stated Housekeeping/Laundry #2 was responsible for cleaning the ice machine. Housekeeping/Laundry #2 stated the ice machine was cleaned two times a week, sometimes more, and was last cleaned two days earlier, with a deep cleaning every week. The Maintenance Director stated the ice machine was cleaned once a month when mechanical components on top of the machine were cleaned and checked, and that dust and buildup were looked for. The Administrator later stated the ice machine should be cleaned immediately and disinfected, and reported that the ice from this machine was used to distribute ice to residents in the facility. Review of the Ice Machine Cleaning Log for July 2025 showed cleaning dates on 7/1, 7/4, 7/8, 7/11, 7/15, 7/18, 7/22, and 7/25.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure proper food storage, cleanliness, and hygiene practices in the kitchen and food service areas. Observations revealed that food items in the refrigerator and freezer were not covered, sealed, or dated, and there was a buildup of grease and residue in various kitchen areas, including the ice machines. The kitchen walls, door frames, and baseboards were found to be in poor condition, with rotten wood, chipped walls, and peeling paint. These deficiencies were observed during multiple inspections, indicating a lack of adherence to professional standards for food storage and kitchen maintenance. Dietary staff were observed not following proper hand hygiene protocols, which included not washing hands after handling dirty objects and before handling clean equipment or food items. Specific instances included dietary employees contaminating gloves, handling clean equipment with unwashed hands, and failing to wash hands after touching dirty objects. These actions were observed during meal preparation and service, posing a potential risk for foodborne illness among the residents. Additionally, expired food items were found in the kitchen, such as a container of baking powder past its expiration date. The facility's hand washing policy, which requires staff to wash hands and exposed portions of their arms during food preparation and after engaging in activities that contaminate the hands, was not followed. These deficiencies had the potential to affect all 82 residents who received meals from the kitchen, highlighting significant lapses in food safety and hygiene practices within the facility.
Medication Security and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper security and storage of medications, specifically controlled substances. On 04/17/2024 at 03:00 PM, a surveyor observed that the refrigerated plastic emergency kit in the Station 1 refrigerator, which contained five 2 milligram/1 milliliter oral Lorazepam syringes and one 2 milligram/1 milliliter injectable Lorazepam syringe, was not in a locked and permanently affixed container. Lorazepam is a controlled substance that requires secure storage due to its potential for abuse and serious side effects. Additionally, at 03:13 PM, the surveyor observed an unattended and unlocked medication cart on Station 2. Both the Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed these observations, acknowledging that the medication cart should not have been left unlocked and unattended, and that the emergency kit should have been in a locked and affixed container. Further investigation revealed that the facility did not have a Medication Storage Policy in place. This was confirmed by the Assistant Director of Nursing (ADON) and the DON. A document provided by Human Resources titled 'Charge Nurse Job Description' indicated that one of the responsibilities of the charge nurse was to ensure the proper storage of medications and controlled substances. The lack of a formal policy and the observed lapses in medication security highlight significant deficiencies in the facility's medication management practices.
Failure to Serve Meals According to Planned Menu
Penalty
Summary
The facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents. Specifically, for one of the two meals observed, the menu indicated that residents on pureed diets were to receive two #8 scoops (totaling 1 cup) of pureed pimento cheese sandwich. However, on 04/16/2024 at 05:06 PM, a dietary employee used a 4-ounce spoon to serve a single scoop (totaling 0.5 cups) of pureed pimento cheese sandwich to these residents. This discrepancy was confirmed during an interview on 04/17/2024 at 11:38 AM, where the dietary employee acknowledged using the incorrect spoon size and serving only one scoop instead of the required two scoops.
Failure to Properly Puree Food for Residents on Pureed Diets
Penalty
Summary
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency, which is necessary to minimize the risk of choking or other complications for residents requiring pureed diets. During an observation on 04/17/2024 at 07:40 AM, a pan of pureed sausage on the steam table was found to be gritty and not smooth. Dietary Employee (DE) #5 acknowledged that the sausage was gritty and should have been pureed longer. Later, at 10:45 AM, DE #5 was observed pureeing lasagna, which was also found to be lumpy with visible pieces of intact noodle. DE #5 admitted that the lasagna should have been pureed longer. These deficiencies were observed during meal preparation and had the potential to affect seven residents who were on pureed diets.
Unclean Shower Room
Penalty
Summary
The facility failed to ensure that one of three shower rooms was clean. On 04/15/2024 at 02:17 PM, a brown substance was observed smeared on the floor in the bathroom on the Medicare Hall. At 02:19 PM, a Certified Nursing Assistant (CNA) identified the substance as bowel movement. On 04/17/2024 at 09:56 AM, the Director of Nursing (DON) confirmed that the shower room should be cleaned after use and between residents. The Administrator also confirmed that soils should be cleaned after every shower and deep cleaned at the end of the day, and that feces should not be present on the shower room floor if the shower is not in use.
Failure to Document and Verify Medications During Discharge
Penalty
Summary
The facility failed to ensure all medications were documented on the discharge summary for Resident #184 when discharging from the facility. Resident #184, who was admitted with a diagnosis of acute systolic (congestive) heart failure, was cognitively intact with a BIMS score of 14. Upon discharge, the resident received another resident's medication, which was not documented on the discharge summary. The caregiver of Resident #184 called the facility to report the error and returned the incorrect medication to the facility. The Administrator confirmed the incident but did not conduct an in-service for the nurses involved. The Director of Nursing (DON) and LPN #2 were interviewed regarding the discharge process. The DON stated that the nurse is responsible for reviewing the resident's orders and pulling the medications, but there was no discharge summary indicating what medications were sent home with Resident #184. LPN #2 admitted to not checking the medications against the physician orders, assuming the night shift had already done so. The LPN acknowledged the importance of verifying medications and reported the incident to the Administrator, who did not provide further training or in-service to address the mistake.
Resident Discharged with Incorrect Medications
Penalty
Summary
The facility failed to ensure that Resident #184 did not receive medications that were not prescribed to them upon discharge. Resident #184, who was admitted with a diagnosis of Acute systolic (congestive) heart failure and had a BIMS score of 14 indicating cognitive intactness, was discharged with another resident's medication. The incident was identified when the caregiver called the facility to report the error and returned the incorrect medications. The discharge summary lacked documentation of the medications sent home with the resident, and the Director of Nursing (DON) was unable to confirm which medications were incorrectly sent home. The Licensed Practical Nurse (LPN) responsible for preparing the medications admitted to not checking the medications against the physician's orders, assuming that the night shift had correctly pulled the medications. The LPN acknowledged the mistake and reported it to the Administrator, who did not provide an in-service for the nurses involved. The Administrator confirmed awareness of the incident but did not take further action to address the error or prevent future occurrences.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Russellville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stella Manor Nursing And Rehabilitation Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Russellville Nursing And Rehabilitation Center | 2.2 mi | ★★★★★ | 8 | 0 |
| Dardanelle Nursing And Rehabilitation Center,inc | 4.5 mi | ★★★★★ | 4 | 0 |
| Atkins Nursing And Rehabilitation Center | 11.3 mi | ★★★★★ | 3 | 0 |
| Mitchell's Nursing Home, Inc | 20.7 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.