Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Village Rehabilitation during CMS and state inspections, most recent first.
A resident with a history of brain hemorrhage and seizures experienced an unwitnessed fall and subsequently showed decreased responsiveness and vomiting. Despite these significant changes, nursing staff delayed notifying the medical provider and waited for the NP to arrive before arranging hospital transfer. The DON later confirmed that immediate physician notification was expected in such cases, and the family expressed concern over the delay. The resident was later found to have a new brain bleed and passed away.
A resident with a history of brain hemorrhage and multiple falls experienced an unwitnessed fall, after which staff initiated neurological checks but failed to document them properly and delayed notifying the medical provider about the resident's change in condition, including vomiting and decreased consciousness. The resident was not sent to the hospital until later in the day, where a brain bleed was diagnosed, and the resident passed away days later. Staff interviews revealed confusion about documentation and escalation procedures, contributing to harm.
The facility did not electronically transmit completed MDS discharge assessments for 16 residents to the CMS System as required. Although the assessments were completed and signed off by a RN, the transmission process was not carried out, resulting in unsubmitted data for multiple residents. The MDS Coordinator was responsible for this process, but the required submissions were not made.
A resident requiring oxygen therapy did not receive proper respiratory care, as their oxygen concentrator humidifier was repeatedly found empty and undated, and the nasal cannula was not labeled or changed as required. Staff interviews revealed confusion and inconsistency regarding responsibility for maintaining and labeling oxygen equipment, leading to lapses in care.
Surveyors found that multiple food items in the kitchen's walk-in freezer, refrigerator, and dry storage were left open to the air, including plant-based patties, dinner rolls, pork sausage, ground beef patties, bread dough, mixed vegetables, cut green beans, potato chips, and sliced ham. The Dietary Manager acknowledged that food should be properly sealed, but the observed items were not stored according to professional standards.
The facility did not maintain required documentation of Legionella water testing since 2021 and staff were observed transporting soiled linens in uncovered bins and handling soiled laundry without wearing aprons, contrary to facility policy and infection control standards.
Three MDS assessments were submitted without the required RN signature certifying completion. Review of records confirmed that the assessments for three residents lacked RN certification, and staff interviews revealed that the MDS Coordinator and an RN from memory care typically handle sign-offs, with the DON stating the MDS Coordinator is responsible for completion.
Failure to Immediately Notify Physician After Resident's Change in Condition Post-Fall
Penalty
Summary
A deficiency was identified when the facility failed to immediately consult with a resident's physician following a significant change in the resident's physical status after a fall. The resident, who had a complex medical history including traumatic subarachnoid hemorrhage, nontraumatic acute subdural hemorrhage, epileptic seizures, and obstructive hydrocephalus, experienced an unwitnessed fall in the early morning hours. Initial assessment by staff indicated the resident was alert and reported no pain, and the physician, DON, and family were reportedly notified. However, subsequent documentation and interviews revealed that the resident exhibited a decrease in level of consciousness and episodes of vomiting, which were not promptly communicated to the medical provider. Nursing staff continued neurological checks and observed that the resident was less responsive than her baseline, requiring manual opening of her eyes for pupil assessment. Despite these concerning signs, the nurse on duty waited for the Nurse Practitioner (NP) to arrive later in the morning before taking further action, citing previous family concerns about hospital transfers and the resident's DNR status. The NP, upon being notified and assessing the resident, immediately recognized the need for hospital evaluation due to the resident's lethargy and vomiting, and arranged for transfer to the emergency room. Interviews with facility staff confirmed that there was a delay in notifying the medical provider about the resident's change in condition, particularly the decrease in responsiveness and vomiting following the fall. The DON stated that such changes should have prompted immediate physician notification. The family expressed concern that the resident was not sent to the hospital promptly, especially given her history of brain bleeds and falls. The resident was later found to have suffered a catastrophic new brain bleed and passed away several days after the incident. The facility's internal investigation did not address the failure to respond to the resident's change in condition.
Failure to Provide Timely Care and Physician Notification After Resident Fall
Penalty
Summary
A resident with a complex medical history, including traumatic subarachnoid hemorrhage, nontraumatic acute subdural hemorrhage, epileptic seizures, and obstructive hydrocephalus, experienced an unwitnessed fall in the early morning hours. The resident was found on the bathroom floor by her husband and was initially assessed as alert, with no pain or apparent neurological deficits. Neurological checks were initiated, and the physician, DON, and family were notified via text. However, documentation of the neurological assessment following the fall could not be located in the medical record. Throughout the morning, the resident exhibited a change in condition, including episodes of vomiting and decreased level of consciousness. Staff noted that the resident was more lethargic than usual and required assistance to open her eyes for neurological checks. Despite these concerning symptoms, the resident was not immediately sent to the hospital. The nurse practitioner was notified later in the morning and, upon assessment, determined that the resident needed to be transported to the emergency room. The resident was sent to the hospital by a non-emergent ambulance, where she was diagnosed with a brain bleed and subsequently passed away four days later. Interviews with facility staff revealed inconsistencies in the process for documenting and escalating care for residents with changes in condition following a fall. Staff were unclear about the handling and storage of neurological check forms, and there was a delay in notifying the medical provider of the resident's deteriorating condition. The facility's investigation did not address the resident's change in condition, and the lack of timely intervention and documentation contributed to the finding of harm for the resident.
Failure to Transmit MDS Discharge Assessments to CMS
Penalty
Summary
The facility failed to electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) discharge assessments to the CMS System for 16 out of 40 sampled residents. Although the MDS discharge assessments for these residents were completed, they were not transmitted as required. The specific residents affected had discharge assessment dates ranging from early January to late April, and the assessments remained unsubmitted to CMS at the time of the survey. Interviews with facility staff revealed that the MDS Coordinator is responsible for generating transmission files after the MDS assessments are signed off by a Registered Nurse. The process includes correcting and resending any rejected transmissions. However, despite this process, the discharge MDS assessments for the identified residents were not transmitted, indicating a breakdown in the facility's procedures for timely and accurate data submission.
Failure to Provide Proper Respiratory Care and Equipment Maintenance
Penalty
Summary
A resident with a history of cerebral infarction, acute respiratory distress syndrome, respiratory failure with hypoxia, chronic obstructive pulmonary disease, and obstructive sleep apnea was observed to have deficiencies in the provision of respiratory care. Multiple observations revealed that the resident's oxygen concentrator humidifier was empty, not dated, and contained a dry white substance. The nasal cannula was also not dated, and there was no indication that it had been changed as required. These issues persisted over several days, with the humidifier remaining empty during repeated checks. Interviews with nursing staff and CNAs revealed confusion and inconsistency regarding responsibility for oxygen equipment maintenance, including changing and labeling cannulas and humidifiers. Staff provided conflicting information about schedules for changing tubing and humidifiers, and there was a lack of clarity about which staff members were responsible for these tasks. The DON confirmed that humidification should be used for residents on higher oxygen flow rates and that equipment should be labeled and changed regularly, but acknowledged uncertainty about current practices and adherence to protocols.
Improper Storage of Food Items in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During two separate walk-throughs of the kitchen, multiple food items in the walk-in freezer and refrigerator, as well as in dry storage, were found open to the air, including plant-based patties, frozen dinner rolls, pork sausage, ground beef patties, bread dough, mixed vegetables, cut green beans, potato chips, and sliced ham. The Dietary Manager confirmed that food in the refrigerators and freezers should be properly sealed to prevent ice burn and preserve food quality, and described the audit and education processes conducted by the Registered Dietitian and himself. However, the observed open food items indicated that these procedures were not consistently followed.
Infection Control Deficiencies in Water Testing and Laundry Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by lapses in water testing and improper handling of soiled laundry. Specifically, the facility was unable to provide documentation of Legionella testing of the water supply since 2021, despite the Water Management Program plan requiring biannual internal testing. Interviews with the Infection Preventionist, Director of Maintenance, and Administrator confirmed that there was no documentation of water testing for Legionella from 2022 onward, and the only available records were from 2019, 2020, and 2021. Additionally, staff were observed collecting and transporting soiled linens in uncovered bins through resident hallways, and loading soiled laundry into washing machines without wearing aprons or protective gowns. Interviews with laundry staff and the Director of Maintenance confirmed that laundry bins should be covered when transporting soiled linens and that staff should wear aprons when handling soiled laundry, but these practices were not consistently followed.
Failure to Obtain RN Signature on MDS Assessments
Penalty
Summary
For three of forty sampled residents, the facility failed to ensure that a registered nurse (RN) signed and certified the completion of Minimum Data Set (MDS) assessments before submission to CMS. Specifically, the entry MDS assessments for three residents did not contain the required RN signature. Review of medical records and MDS assessments confirmed the absence of RN certification for these assessments. During interviews, the MDS Coordinator stated that he typically meets weekly with an RN from the memory care unit for MDS sign-off, while the Director of Nursing indicated that the MDS Coordinator is responsible for completing the assessments.
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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 Taylorsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Monument Healthcare Taylorsville | 1.9 mi | ★★★★★ | 15 | 0 |
| Rocky Mountain Care - Hunter Hollow | 3.3 mi | ★★★★★ | 19 | 0 |
| Cascades At Riverwalk | 3.3 mi | ★★★★★ | 20 | 0 |
| Aspen Ridge West Transitional Rehab | 3.7 mi | ★★★★★ | 11 | 0 |
| Meadow Peak Rehabilitation | 4 mi | ★★★★★ | 0 | 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.