Legacy Village Rehabilitation
Legacy Village Rehabilitation in Taylorsville, UT — inspection on December 1, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
resident 2 to the hospital because resident 2 had a Do Not Resuscitate (DNR) order and the last time he had sent her to the hospital after a fall the family was upset because resident 2 had not been injured. LPN 1 stated resident 2 was pretty tired on 10/13/25 and not at baseline. On 12/1/25 at 1:08 PM, a follow-up interview was conducted with the DON.
The DON stated that it would be concerning if staff had to open a resident's eyes to perform pupil assessments during neurological checks and would expect staff to call the doctor immediately and not wait until later for a medical provider to come into the facility. On 12/1/25 at 1:13 PM, resident 2's family member was interviewed via email.
The family member stated that resident 2 fell on the morning of 10/13/25 and the facility had not immediately sent her to the emergency room to check for internal bleeding.
The family member stated that this was concerning given resident 2's history of falls while at the facility.
The family member stated that resident 2 had a massive new brain bleed that was confirmed by a CT (cat) scan that was catastrophic and resident 2 passed away on 10/17/25. It should be noted that when the facility submitted to the State Survey Agency (SSA) their 5-day investigation findings, they concluded that resident 2 had an unfortunate fall and had not addressed the resident's change in condition.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/01/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Legacy Village Rehabilitation
3251 West 5400 South Taylorsville, UT 84129
SUMMARY STATEMENT OF DEFICIENCIES
conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that he started his shift on 10/13/25 at 6:30 AM and got the report from another nurse that resident 2 had fallen earlier in the morning. LPN 1 stated that the night nurse had passed on in report that resident 2 was having a hard time opening her eyes and had to have her eyes opened by hand to perform neurological checks to assess her pupils and that resident 2's family did not want her to go to the hospital. LPN 1 stated that he assumed the night nurse had contacted the MD. LPN 1 stated that he continued the neurological checks when he started his shift and resident 2 was less responsive than her baseline and he also had to use his hands to open resident 2's eyes to perform the pupil assessment to see if they were more reactive. LPN 1 stated that he sat resident 2 up for breakfast and administered morning medications which resident 2 vomited up. LPN 1 stated that the vomiting episode was unwitnessed by him and resident 2's husband came and informed him. LPN 1 stated that resident 2 continued to not be at baseline and was still out of it. LPN 1 stated that he was concerned because resident 2 had vomited and he wanted the NP to see her because of this. LPN 1 stated that he waited for the NP to come in before sending resident 2 to the hospital because resident 2 had a Do Not Resuscitate (DNR) order and the last time he had sent her to the hospital after a fall the family was upset because resident 2 had not been injured. LPN 1 stated resident 2 was pretty tired on 10/13/25 and not at baseline. LPN 1 stated that the facility did not have alarms to alert staff if a resident got out of bed or a chair for high risk fall residents which resident 2 was.On 12/1/25 at 1:08 PM, a follow-up interview was conducted with the DON.
The DON stated that it would be concerning if staff had to open a resident's eyes to perform pupil assessments during neurological checks and would expect staff to call the doctor immediately and not wait for a medical provider to come into the facility. On 12/1/25 at 1:13 PM, resident 2's family member was interviewed via email.
The family member stated that resident 2 fell on the morning of 10/13/25 and the facility had not immediately sent her to the emergency room to check for internal bleeding.
The family member stated that this was concerning given resident 2's history of falls while at the facility.
The family member stated that resident 2 had a massive new brain bleed that was confirmed by a CT (cat) scan that was catastrophic and resident 2 passed away on 10/17/25. It should be noted that when the facility submitted to the State Survey Agency (SSA) their 5-day investigation findings, they concluded that resident 2 had an unfortunate fall and had not addressed the resident's change in condition.
Facility ID: