Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 The Legacy Rehab & Care Center during CMS and state inspections, most recent first.
A resident with a BIMS of 15, walker use, and continuous O2 was injured when her wheelchair tipped backward during van transport. The driver failed to secure the wheelchair’s front clamps, and the resident reported hitting her head and sustaining a skin tear to her upper arm after the chair flipped and struck items in the van.
A resident with a lower right femur fracture and intact cognition was discharged AMA after signing an AMA form and understanding the risks. The facility did not include this discharge in its monthly notification to the State LTC Ombudsman, despite policy and staff expectations that all discharges, including AMA, be reported.
Wheelchair Not Secured During Transport
Penalty
Summary
The facility failed to ensure a resident was free from an avoidable accident related to transportation. Resident #44 was re-admitted with diagnoses including unspecified gangrene, acute kidney failure, and acute respiratory failure. The resident’s care plan identified risks related to falls, the need for assistance with ambulation and transfers, and the need for supplemental oxygen, with interventions to ensure the oxygen tank was turned on and the nasal cannula was in place before leaving the resident. The resident’s MDS showed a BIMS score of 15, indicating cognitive intactness, use of a walker for mobility, moderate staff assistance with showering and toileting, and continuous supplemental oxygen. During transport in a van, the resident’s wheelchair tipped backwards. The incident note stated the resident reported hitting her head, and the driver pulled over and assisted the wheelchair back upright. The resident declined transfer to the hospital and continued to her appointment. After returning to the facility, the resident was assessed and found to have a small bump to the head and a skin tear with flap to the left upper outer arm. The post-fall evaluation documented an unwitnessed fall in the transportation van with injury, involving a wheelchair and oxygen use. Interviews later confirmed the driver had forgotten to secure the two front clamps on the wheelchair, and the resident stated she believed the wheelchair had not been locked in place before it tipped backward during a turn.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to ensure that discharge notifications were made to the representative of the Office of the State Long-Term Care Ombudsman for one of seven reviewed residents. Specifically, a resident who was admitted with a lower right femur fracture and had intact cognition, as indicated by a BIMS score of 15, was discharged against medical advice (AMA). Documentation showed that the resident signed an AMA form after being informed of the risks and verbalizing understanding. However, a review of the facility's email notifications to the Ombudsman for the relevant month did not include this resident's discharge. Interviews with facility staff, including the Social Services Director and the Director of Nursing, confirmed that it was the facility's policy and expectation to notify the Ombudsman of all discharges, including those occurring AMA, through a monthly report. The Social Services Director acknowledged that the resident's discharge should have been included in the report but was omitted. Facility policy also required that a copy of all discharge notices, including AMA discharges, be sent to the Ombudsman as soon as practicable, which did not occur in this instance.
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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 Bullhead City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Desert Highlands Care Center | 29.7 mi | ★★★★★ | 0 | 0 |
| The Gardens Rehab & Care Center | 29.7 mi | ★★★★★ | 6 | 0 |
| The Lingenfelter Center | 29.7 mi | ★★★★★ | 1 | 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 August 2026) and official state health department websites.