Legacy Transitional Care & Rehabilitation

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observations, staff interviews, and review of the facility's policy titled Facility Maintenance Policy, the facility failed to ensure that three of 14 shared bedrooms on the 400 hall (rooms [ROOM NUMBER]) were maintained in good repair. Specifically, rooms [ROOM NUMBER] were not free from chipped and peeling paint, scuffed sheetrock, and damaged or broken electrical outlet. Findings include: Review of the policy titled Facility Maintenance Policy revealed the Maintenance Policy outlines the procedures and responsibilities for ensuring the proper operation and upkeep of the nursing home's facilities. It includes guidelines for plant operations and regular checks of the call light system to ensure the safety and comfort of all residents.Standard of Practice: Plant Operations revealed the plant operations is the maintenance and functionality of all mechanical, electrical, and plumbing within the facility. This includes heating, ventilation, air conditioning (HVAC), water supply, and emergency power systems.Responsibilities include: Conducting daily inspections of all critical systems. Performing routine maintenance as per manufacturer and regulatory guidelines. Documenting all maintenance activities and inspections. Responding promptly to any system failures or malfunctions. Tels task rounds are conducted on a weekly, monthly, and annual basis per system.Resident Rooms: Patient rooms are inspected weekly for cleanliness, functionality of fixtures, and safety compliance. Repairs and maintenance issues are addressed promptly to ensure resident comfort and safety. An observation on 9/30/2025 at 11:36 am during tour and screening of residents revealed in room [ROOM NUMBER], bed two, a damaged and broken outlet. An observation on 9/30/2025 at 11:55 am

during tour and screening of residents revealed in room [ROOM NUMBER], next to bed two, wall paint that was peeled and scraped with scuffed sheetrock. An observation on 9/30/2025 at 12:19 pm during tour and screening of residents revealed in room [ROOM NUMBER], bed one, wall paint that was peeled and scraped with scuffed sheetrock, holes in the wall, and an overbed light that was inoperable. An observation

on 10/1/2025 at 1:03 pm during tour and screening of residents revealed in room [ROOM NUMBER], bed two, a damaged and broken outlet. An observation on 10/1/2025 at 1:30 pm revealed in room [ROOM NUMBER], next to bed two, wall paint that was peeled and scraped with scuffed sheetrock. An observation

on 10/1/2025 at 1:42pm during tour and screening of residents revealed in room [ROOM NUMBER], bed one, wall paint that was peeled and scraped with scuffed sheetrock, holes in the wall, and an overbed light that was inoperable. An interview on 10/1/2025 at 4:05 pm during walking rounds with the Maintenance Director confirmed damaged walls with peeled paint and chipped, scuffed sheetrock, a damaged and broken outlet, and the overbed light to be inoperable. An interview on 10/2/2025 at 2:09 pm with the Administrator revealed that she was aware of the environmental concerns and stated that three Maintenance Personnel would be assigned to round the facility, each responsible for a designated floor.

She further indicated that additional tools would be implemented to support daily checks.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Legacy Transitional Care & Rehabilitation

460 Auburn Avenue N.E.

Atlanta, GA 30312

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited LEGACY TRANSITIONAL CARE & REHABILITATION in ATLANTA, GA for a deficiency under regulatory tag F-F0645 during a standard health inspection conducted on 2025-11-17.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: PASARR screening for Mental disorders or Intellectual Disabilities

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 3 deficiencies cited during this inspection of LEGACY TRANSITIONAL CARE & REHABILITATION.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-12-11.

F 0919

Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observations, resident and staff interviews, and review of the facility policies titled, Call light system/Light Policy, and Facility Maintenance Policy, the facility failed to ensure that the call light communication system was functioning adequately to allow residents to call for staff assistance in two out of seven restrooms (200 hall) and two of 14 rooms (301,305) on 300 hall.Findings include:Review of the facility policy titled, Call System/Light Policy, revise date of May 15, 2025, revealed under Policy Statement: The purpose of the Resident Call System shall allow residents to call for staff assistance through a communication system that relays the call directly to a staff member or to a centralized staff work area. Under Standard of Practice: Equipment: 1. Bedside call light in functioning order 2. Emergency call light in working order.Review of the facilities policy titled, Facility Maintenance Policy, dated July 2025, revealed under Standard of Practice: Plant Operations; Responsibilities included: conducting daily inspections of all critical systems. Resident monitoring systems are a critical component for resident safety and communication. Regular checks are necessary to ensure these monitoring systems are always operational.1.Observation on 9/30/2025 at 11:05 am during tour of resident's rooms revealed in room [ROOM NUMBER] the call light system was hanging off the wall and wires were exposed. The button on call system for the room was not functioning. Call light was tested by pushing the button and there was no sound or indicator light illuminating over the doorway. In room [ROOM NUMBER] the call light system was pulled out from the wall and hanging and was not functioning. Call light was tested by pushing the red button and there was no sound or indicator light illuminating over the doorway.Observation on 9/30/2025 at 11:15 am on the 200 hall two bathrooms connecting rooms [ROOM NUMBERS], 203 and 204 revealed the call light system was hanging from the wall and wires were exposed, and the system was not functioning. Walking rounds on 9/30/2025 at 1:24 pm with Maintenance Director verified rooms 301, 305 and bathrooms on 200 hallway had non-functioning call lights.2. During an observation on 9/30/2025 at 11:12 am in the shared bathroom for 201 and 202 revealed

the emergency call device was detached from the wall.During an observation on 9/30/2025 at 11:14 am in

the shared bathroom for 203 and 204 revealed the emergency call device was detached from the wall.During an observation and interview on 10/1/2025 at 4:07 pm with Maintenance Director confirmed the call devices in the shared bathrooms were detached from the wall. Continued interview also revealed that

he does conduct audits for the call devices to ensure they work.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet