Legacy Transitional Care & Rehabilitation

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

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/17/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Legacy Transitional Care & Rehabilitation

460 Auburn Avenue N.E.

Atlanta, GA 30312

SUMMARY STATEMENT OF DEFICIENCIES