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THE LEGACY REHAB & CARE CENTER

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THE LEGACY REHAB & CARE CENTER VS
Nursing Homes USA
General
City BULLHEAD CITY   0% Nursing Homes USA have BULLHEAD CITY
State attribute explanation AZ   0.9% Nursing Homes USA have AZ
Street 2812 SILVER CREEK ROAD  
Zip Code 86442  
Phone 9287631404  
Overall Star Rating
3.11
Health Inspections Star Rating
2.83
Nurse Staffing Star Rating
3.17
Quality Measures Star Rating
3.31
RN Only Star Rating
3.17
Number of Certified Beds
120 
108.94
Total Number of Residents
88 
91.25
Percent of Occupied Beds
73 %
83.65 %
Health Survey Date 5/1/2012  
Fire Survey Date 5/9/2012  
Sprinkler Status Fully Sprinklered  90.2% Nursing Homes USA have Fully Sprinklered
Program Participation Medicare And Medicaid  91.5% Nursing Homes USA have Medicare and Medicaid
Type of Ownership For Profit - Corporation  56.7% Nursing Homes USA have For profit - Corporation
Located Within a Hospital? No  93.6% Nursing Homes USA don't have Located Within a Hospital?
Multi Nursing Home Ownership? No  45.1% Nursing Homes USA don't have Multi Nursing Home Ownership?
Resident and Family Councils RESIDENT   66% Nursing Homes USA have RESIDENT
Continuing Care Retirement Community? No  90.9% Nursing Homes USA don't have Continuing Care Retirement Community?
Quality Indicator Survey? Yes  31.3% Nursing Homes USA have Quality Indicator Survey?
Special Focus Facility? No  99% Nursing Homes USA don't have Special Focus Facility?
Civil Money Penalty Count
58.16
Total Enforcement Actions Count
56.31
# of deficiencies 29  
Staff Information
Number of Residents
88 
91.38
Number of RN Hours Per Resident Per Day
0.67 
0.77
Number of LPN/LVN Hours Per Resident Per Day
0.85 
0.84
Total Number of Licensed Staff Hours Per Resident Per Day
1.52 
1.59
Number of CNA Hours Per Resident Per Day
0.06 
5.49
Number Therapy Hours Per Resident Per Day
0.06 
0.10
Environmental Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading.
survey Date: 03/17/2011
date Of Correction: 04/13/2011 
Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.
survey Date: 03/17/2011
date Of Correction: 04/13/2011 
Deficiency #3 Scope: Many
level Of Harm: 2
deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading.
survey Date: 12/18/2009
date Of Correction: 02/25/2010 
Deficiency #4 Scope: Few
level Of Harm: 2
deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.
survey Date: 12/18/2009
date Of Correction: 02/25/2010 
Mistreatment Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: 1) Hire Only People With No Legal History Of Abusing, Neglecting Or Mistreating Residents; Or 2) Report And Investigate Any Acts Or Reports Of Abuse, Neglect Or Mistreatment Of Residents.
survey Date: 03/17/2011
date Of Correction: 04/13/2011 
Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Keep Each Resident Free From Physical Restraints, Unless Needed For Medical Treatment.
survey Date: 03/17/2011
date Of Correction: 04/13/2011 
Deficiency #3 Scope: Some
level Of Harm: 2
deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property.
survey Date: 12/18/2009
date Of Correction: 02/25/2010 
Deficiency #4 Scope: Some
level Of Harm: 3
deficiency: 1) Hire Only People With No Legal History Of Abusing, Neglecting Or Mistreating Residents; Or 2) Report And Investigate Any Acts Or Reports Of Abuse, Neglect Or Mistreatment Of Residents.
survey Date: 12/18/2009
date Of Correction: 02/25/2010 
Deficiency #5 Scope: Some
level Of Harm: 3
deficiency: Write And Use Policies That Forbid Mistreatment, Neglect And Abuse Of Residents And Theft Of Residents' Property.
survey Date: 12/18/2009
date Of Correction: 02/25/2010 
Resident Rights Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 1
deficiency: Allow Residents To Easily View The Results Of The Nursing Home's Most Recent Survey.
survey Date: 03/17/2011
date Of Correction: 04/13/2011 
Deficiency #2 Scope: Some
level Of Harm: 1
deficiency: Properly Hold, Secure And Manage Each Resident's Personal Money Which Is Deposited With The Nursing Home.
survey Date: 03/17/2011
date Of Correction: 04/13/2011 
Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident.
survey Date: 03/17/2011
date Of Correction: 04/13/2011 
Deficiency #4 Scope: Some
level Of Harm: 2
deficiency: Reasonably Accommodate The Needs And Preferences Of Each Resident.
survey Date: 12/18/2009
date Of Correction: 02/25/2010 
Deficiency #5 Scope: Few
level Of Harm: 3
deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident.
survey Date: 12/18/2009
date Of Correction: 02/25/2010 
Quality Care Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Make Sure That Each Resident Who Enters The Nursing Home Without A Catheter Is Not Given A Catheter, And Receive Proper Services To Prevent Urinary Tract Infections And Restore Normal Bladder Function.
survey Date: 03/17/2011
date Of Correction: 04/13/2011 
Deficiency #2 Scope: Few
level Of Harm: 3
deficiency: Give Each Resident Enough Fluids To Keep Them Healthy And Prevent Dehydration.
survey Date: 12/18/2009
date Of Correction: 02/25/2010 
Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: Make Sure That Each Resident Who Enters The Nursing Home Without A Catheter Is Not Given A Catheter, And Receive Proper Services To Prevent Urinary Tract Infections And Restore Normal Bladder Function.
survey Date: 12/18/2009
date Of Correction: 02/25/2010 
Deficiency #4 Scope: Few
level Of Harm: 3
deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores.
survey Date: 12/18/2009
date Of Correction: 02/25/2010 
Deficiency #5 Scope: Some
level Of Harm: 3
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 12/18/2009
date Of Correction: 02/25/2010 
Deficiency #6 Scope: Some
level Of Harm: 2
deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.
survey Date: 12/18/2009
date Of Correction: 02/25/2010 
Deficiency #7 Scope: Some
level Of Harm: 2
deficiency: Provide Medically-related Social Services To Help Each Resident Achieve The Highest Possible Quality Of Life.
survey Date: 12/18/2009
date Of Correction: 02/25/2010 
Administration Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 1
deficiency: Post Nurse Staffing Information/data On A Daily Basis.
survey Date: 03/17/2011
date Of Correction: 04/13/2011 
Deficiency #2 Scope: Some
level Of Harm: 2
deficiency: Set Up An Ongoing Quality Assessment And Assurance Group To Review Quality Deficiencies Quarterly, And Develop Corrective Plans Of Action.
survey Date: 12/18/2009
date Of Correction: 02/25/2010 
Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.
survey Date: 12/18/2009
date Of Correction: 02/25/2010 
Deficiency #4 Scope: Few
level Of Harm: 2
deficiency: Give Or Get Quality Lab Services/tests In A Timely Manner To Meet The Needs Of Residents.
survey Date: 12/18/2009
date Of Correction: 02/25/2010 
Deficiency #5 Scope: Some
level Of Harm: 2
deficiency: Choose A Doctor To Serve As The Medical Director To Create Resident Care Policies And Coordinate Medical Care In The Facility.
survey Date: 12/18/2009
date Of Correction: 02/25/2010 
Pharmacy Service Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Make Sure That Residents Are Safe From Serious Medication Errors.
survey Date: 12/18/2009
date Of Correction: 02/25/2010 
Nutrition and Dietary Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Store, Cook, And Serve Food In A Safe And Clean Way.
survey Date: 03/17/2011
date Of Correction: 04/13/2011 
Deficiency #2 Scope: Some
level Of Harm: 2
deficiency: Store, Cook, And Serve Food In A Safe And Clean Way.
survey Date: 12/18/2009
date Of Correction: 02/25/2010 
Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication
19.8 %
25.09 %
Percent of long-stay residents whose need for help with daily activities has increased
3.8 %
32.95 %
Percent of long-stay residents who self-report moderate to severe pain 22.2:1 % 
Percent of long-stay high-risk residents with pressure ulcers
15.6 %
12.58 %
Percent of long-stay residents who lose too much weight
2.4 %
11.83 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder
43.2 %
44.54 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder
5.2 %
15.63 %
Percent of long-stay residents with a urinary tract infection
17.9 (64.2) %
13.46 %
Percent of long-stay residents who have depressive symptoms
75.2 %
28.38 %
Percent of long-stay residents who were physically restrained
75.2 %
43.68 %
Percent of short-stay residents who self-report moderate to severe pain
37.7 %
25.02 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
94.4 %
84.64 %
Percent of short-stay residents with Pressure ulcers that are new or worsened
94.7 %
83.94 %
Percent of short-stay residents who newly received an antipsychotic medication
75.2 %
45.90 %
Percent of long-stay residents experiencing one or more falls with major injury
3.4 %
15.52 %
Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication
17.4 %
25.39 %
Percent of long-stay residents whose need for help with daily activities has increased
3.4 %
23.70 %
Percent of long-stay residents who self-report moderate to severe pain
22.9 %
14.10 %
Percent of long-stay high-risk residents with pressure ulcers
13.5 %
9.22 %
Percent of long-stay residents who lose too much weight
3.9 %
8.50 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder
48.8 %
43.38 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder
4.3 %
10.65 %
Percent of long-stay residents with a urinary tract infection
18.5 %
9.58 %
Percent of long-stay residents who have depressive symptoms
0.4 %
19.86 %
Percent of long-stay residents who were physically restrained
75.2 %
38.53 %
Percent of long-stay residents experiencing one or more falls with major injury
2.9 %
10.73 %
Percent of short-stay residents who self-report moderate to severe pain
40.1 %
24.76 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
96.8 %
81.44 %
Percent of short-stay residents with Pressure ulcers that are new or worsened
95.8 %
74.75 %
Percent of short-stay residents who newly received an antipsychotic medication
19.3 %
17.34 %

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