Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Legacy Post Acute Care during CMS and state inspections, most recent first.
A resident with stage 4 kidney disease, anxiety, and dementia was allegedly subjected to hair pulling by a CNA during ADL care, an event witnessed by another CNA who did not immediately report the incident to management. Instead, the witness informed a coworker the next day, who then notified the DSD, leading to a written statement being obtained and the incident being faxed to CDPH more than 24 hours after it occurred. Interviews with the DON, DSD, and staff confirmed that the allegation was not reported immediately, contrary to facility policies requiring prompt reporting of suspected abuse to the administrator and appropriate agencies.
A resident requested copies of their medical records both verbally and in writing, but the facility did not provide the records until several months later, despite multiple follow-up communications. The delay resulted in the resident receiving the records only a few days before a court date, limiting their ability to prepare and share the information.
A facility failed to maintain a current copy of a resident's Advance Directive in their medical record, as required by policy. Despite the resident having an intact mental status and the importance of the document for guiding care during emergencies, the Social Services Director and Medical Records Director could not locate it in the electronic or paper records. This oversight could lead to the resident receiving unwanted treatment.
A resident's discharge assessment was inaccurately completed by the facility staff, with the MDS indicating a discharge to a hospital instead of the resident's actual discharge to home. This error was confirmed through a review of various records and interviews with the MDSC and DON, who acknowledged the mistake and the importance of accurate data entry.
A resident admitted with metabolic encephalopathy did not receive a written summary of their baseline care plan, despite having an intact mental status. The facility's policy required offering a copy of the care plan to residents or their representatives, but this was not done. The resident confirmed they did not receive or sign the care plan summary, leaving them uninformed of their initial care plan.
A facility failed to maintain a medication error rate below 5%, with errors observed in the administration of Breyna and QVAR inhalers, and Dorzolamide eye drops. Nurses did not follow proper administration techniques, such as instructing residents to hold their breath or ensuring the sterility of eye drop administration.
The facility failed to maintain the medication refrigerator within the required temperature range of 36 F to 46 F, as outlined in their policy. Observations revealed the temperature was 34 F, and logs showed instances of 32 F. The refrigerator contained insulin, vaccines, and other medications. Temperature logs for previous months had missing entries. The Assistant DON acknowledged the issue and was unaware of it prior to the observation.
A facility failed to follow infection control protocols when a staff member transported a resident's clothing without using a clean linen cart, amidst a COVID outbreak. The staff member carried the clothes close to his body without gloves, in a hallway with other residents and staff present. Interviews revealed that the facility's policy required clean laundry to be transported in a covered cart, which was not followed, potentially risking cross-contamination.
Delayed Reporting of Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to ensure timely reporting of an alleged abuse incident involving Resident 1 to the California Department of Public Health (CDPH). Resident 1, who had stage 4 kidney disease, anxiety, and dementia, was allegedly subjected to hair pulling by CNA 3 during ADL care on the morning of 2/25/26 at around 6 a.m., as witnessed by CNA 1. CNA 1 did not report the incident to management on the day it occurred and instead informed CNA 2 the following day, stating she believed she had 24 hours to report the incident. CNA 2 then notified the Director of Staff Development (DSD) in the early morning of 2/26/26, and the DSD contacted CNA 1 to obtain a written statement about the incident. The facility faxed the abuse incident report to CDPH on 2/26/26 at 8:40 a.m., more than 24 hours after the alleged incident occurred. Interviews with the DON, DSD, and CNA 2 confirmed that the alleged abuse was not reported immediately as required. The DON stated that CNA 1 did not report the allegation directly to her and that the delay in reporting did not meet her expectations. Review of the facility’s policies titled “Abuse Investigation and Reporting” and “Alleged or Suspected Abuse and Crime Reporting” showed that all employees are responsible for immediately reporting suspected or alleged abuse to the administrator and appropriate officials, and that all reports must be promptly reported to local, state, and federal agencies and thoroughly investigated. The delay in reporting the alleged abuse incident was inconsistent with these policies.
Failure to Timely Provide Resident Access to Medical Records
Penalty
Summary
The facility failed to provide a resident with timely access to their requested medical records. The resident verbally requested copies of their medical records from the administrator in December 2023 and subsequently submitted a written request to the facility's receptionist in January 2024. Despite multiple follow-up communications, including emails and text messages to the facility's attorneys, the resident did not receive the requested records until mid-June 2025, which was only three days before a scheduled court date. The receptionist confirmed receiving a handwritten note from the resident and passing it to the administrator, but did not read its contents. The Medical Record Coordinator (MRC) stated that she informed the resident a consent form was required but never received the completed form or saw the resident in person. Internal emails showed that the administrator instructed the MRC to gather the resident's complete medical record for the defense firm, and the MRC sent the electronic medical record to the administrator in February 2025. The facility's policy allows residents to request their own records without additional authorization, but the records were not provided to the resident within the expected timeframe. The MRC acknowledged that records should be provided within 72 hours of a request. The delay in providing the records resulted in the resident receiving them only shortly before a court date, limiting the time available to prepare and share the information as needed.
Failure to Maintain Current Advance Directive in Resident's Medical Record
Penalty
Summary
The facility failed to ensure that a resident's medical record contained a current copy of their Advance Directive, which is a written instruction regarding the provision of health care when the individual is incapacitated. This deficiency was identified during a review of the resident's admission record and Minimum Data Set (MDS), which indicated that the resident had an intact mental status. Despite this, the Social Services Director (SSD) and Medical Records Director (MRD) were unable to locate the Advance Directive in either the electronic health record (EHR) or the paper chart. The SSD acknowledged that the Advance Directive was not uploaded and stated that the MRD is responsible for auditing the POLST and obtaining a copy of the Advance Directive from the family. The absence of the Advance Directive in the resident's records was confirmed through interviews with the SSD, MRD, and the resident himself, who emphasized the importance of having the document on file to guide staff in case of an emergency. The facility's policy and procedure on Advance Directives, dated December 2016, requires the SSD or designee to inquire about the existence of any written advance directive prior to or upon admission. The failure to have the Advance Directive readily available could potentially lead to the resident receiving unwanted treatment or not receiving care aligned with their wishes.
Inaccurate Discharge Assessment Entry for a Resident
Penalty
Summary
The facility nursing staff failed to accurately complete the discharge assessment for one resident, identified as Resident 73, by entering the wrong discharge disposition in the Minimum Data Set (MDS). The MDS indicated that the resident was discharged to a Short-Term General Hospital, whereas the resident was actually discharged to their home. This error was identified during a review of the resident's Face Sheet, Interdisciplinary Treatment Discharge Summary notes, Physician Discharge Summary, and Physician Order Summary, all of which confirmed the resident's discharge to home. The discrepancy was further confirmed during interviews with the Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON). The MDSC acknowledged the error and stated that it would be corrected. The DON emphasized the importance of accurate encoding for maintaining accuracy in resident assessments. The facility's policy and procedure on Resident Assessment Instrument, dated 2010, outlines the purpose of assessments to describe residents' capabilities and identify impairments, which underscores the significance of accurate data entry.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to a resident, identified as Resident 59, upon their admission. Resident 59 was admitted with a diagnosis of metabolic encephalopathy and was their own responsible party. The Minimum Data Set (MDS) assessment indicated that Resident 59 had an intact mental status with a BIMS score of 14 out of 15. Despite this, the baseline care plan summary was not provided to Resident 59 or their responsible party, as confirmed by interviews with the Licensed Vocational Nurse (LVN) and the Minimum Data Set Coordinator (MDSC). The MDSC noted that the resident's daughter attended the care conference via telephone, but the baseline care plan summary was not given because it was not requested. The facility's policy required that residents or their representatives be offered a copy of the baseline care plan, but this was not adhered to in the case of Resident 59. During an interview, Resident 59 confirmed that they did not receive or sign the baseline care plan summary. The facility's failure to provide this document left Resident 59 uninformed of the initial plan of care and services, as the acknowledgment section of the baseline care plan summary remained unsigned and undated.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an observed error rate of 11% during a medication pass. Three medication errors were identified among two residents. The first error involved the administration of Breyna, an inhaler for asthma and COPD, where the nurse did not instruct the resident to hold their breath for the recommended 10 seconds after inhalation, nor did they wait the required one-minute interval between puffs. This improper technique could compromise the medication's effectiveness. The second error involved the administration of Dorzolamide eye drops, where the nurse allowed the dropper tip to contact the resident's eyelashes, risking contamination. The third error involved the administration of QVAR, another inhaler, where the nurse failed to instruct the resident to exhale before inhalation and to hold their breath for 5 to 10 seconds afterward. These errors in medication administration techniques were acknowledged by the staff involved, indicating a lapse in adherence to proper procedures.
Medication Refrigerator Temperature Deficiency
Penalty
Summary
The facility failed to maintain the medication refrigerator within the required temperature range of 36 F to 46 F, as outlined in their policy. During an observation, it was noted that the temperature of the refrigerator was 34 F, which is below the acceptable range. This refrigerator contained multiple medications, including insulin, vaccines, eye drops, and a refrigerated emergency kit. A review of the temperature logs for January revealed four instances where the temperature was recorded as 32 F, which is also below the required range. Additionally, for the months of December and November, there were seven instances where the temperature logs were either missing or not recorded. During an interview, the Assistant Director of Nursing acknowledged the temperature was too low and admitted to being unaware of the issue prior to the observation. The facility's policy requires that medications needing refrigeration be stored between 36 F and 46 F, which was not adhered to in this case.
Infection Control Breach in Laundry Handling
Penalty
Summary
The facility failed to adhere to its infection prevention and control policy when a housekeeper/laundry staff member transported a resident's personal clothing without using a clean linen cart. During an observation, the staff member was seen carrying several pieces of clothing on hangers, close to his body, without wearing gloves, as he walked down the hallway. This action occurred in a hallway where other staff and residents were present, and where enhanced barrier precautions were in place for several residents due to a recent COVID outbreak. Interviews with the Infection Control Preventionist and the Director of Staffing Development revealed that the facility had experienced a COVID outbreak affecting 32 residents and 15 staff members. The facility's policy required clean laundry to be transported in a covered cart, separate from soiled laundry, to prevent cross-contamination. However, the housekeeper/laundry staff member admitted to not using a clean cart for transporting laundry, which was confirmed by the Housekeeper/Maintenance Supervisor. Additionally, the same staff member was observed wearing a laundry apron outside the facility and returning with it on, potentially compromising infection control measures.
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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 Martinez
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alhambra Post Acute | 2.5 mi | ★★★★★ | 2 | 0 |
| Bayberry Skilled Nursing & Healthcare Center | 2.9 mi | ★★★★★ | 16 | 0 |
| Willow Pass Healthcare Center | 3.9 mi | ★★★★★ | 6 | 0 |
| Concord Post Acute | 4 mi | ★★★★★ | 4 | 0 |
| Rosewood Post Acute | 4.1 mi | ★★★★★ | 6 | 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 June 2026) and official state health department websites.