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Health Inspection Summary

Legacy North Royalton

9055 West Sprague Road

Parma, OH 44133

(440) 842-4967

Deficiency Category	Inspection Date: 1/31/24 Complaint Reporting Period: 5/1/24 - 4/30/25	Inspection Date: 9/16/21 Complaint Reporting Period: 5/1/23 - 4/30/24	Inspection Date: 5/14/19 Complaint Reporting Period: 5/1/22 - 4/30/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies	0	0	2
Quality of Life and Care Deficiencies	1	2	2
Infection Control Deficiencies	0	2	1
Resident Assessment and Care Planning Deficiencies	1	1	0
Nursing and Physician Services Deficiencies	0	0	1
Resident Rights Deficiencies	1	0	1
Nutrition and Dietary Deficiencies	0	0	1
Pharmacy Service Deficiencies	0	0	0
Environmental Deficiencies	0	0	0
Administration Deficiencies	1	0	0

Detailed result for inspection on 1/31/24

Date of last standard health inspection:	1/31/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 5/1/24 - 4/30/25	8/28/24Read the full report (PDF)
Date(s) of infection control inspection(s) between 5/1/24 - 4/30/25	No infection control inspections
Total number of Health Deficiencies for this nursing home:	4
Average number of Health Deficiencies in Ohio:	10.3
Average number of Health Deficiencies in the United States:	9.6

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	8/28/24	9/10/24	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	8/28/24	9/10/24	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
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.	1/31/24	2/13/24	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.	1/31/24	2/13/24	1 - Potential for minimal harm	Many

Detailed result for inspection on 9/16/21

Date of last standard health inspection:	9/16/21Read the full report (PDF)
Date(s) of complaint inspection(s) between 5/1/23 - 4/30/24	12/6/23Read the full report (PDF) 7/31/23Read the full report (PDF)
Date(s) of infection control inspection(s) between 5/1/23 - 4/30/24	12/6/23Read the full report (PDF)
Total number of Health Deficiencies for this nursing home:	5
Average number of Health Deficiencies in Ohio:	10.5
Average number of Health Deficiencies in the United States:	9.5

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide care and assistance to perform activities of daily living for any resident who is unable.	9/16/21	10/21/21	2 - Minimal harm or potential for actual harm	Few
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	9/16/21	10/21/21	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	12/6/23	12/26/23	4 - Immediate jeopardy to resident health or safety	Many
Provide and implement an infection prevention and control program.	9/16/21	10/21/21	2 - Minimal harm or potential for actual harm	Few

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	7/31/23	8/1/23	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
No Resident Rights Deficiencies were found during this inspection period.

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 5/14/19

Date of last standard health inspection:	5/14/19Read the full report (PDF)
Date(s) of complaint inspection(s) between 5/1/22 - 4/30/23	11/16/22Read the full report (PDF) 6/22/22Read the full report (PDF)
Date(s) of infection control inspection(s) between 5/1/22 - 4/30/23	6/22/22Read the full report (PDF)
Total number of Health Deficiencies for this nursing home:	8
Average number of Health Deficiencies in Ohio:	9.6
Average number of Health Deficiencies in the United States:	8.8

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Protect each resident from the wrongful use of the resident's belongings or money.	11/16/22	12/5/22	2 - Minimal harm or potential for actual harm	Some
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	11/16/22	12/5/22	2 - Minimal harm or potential for actual harm	Few

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide activities to meet all resident's needs.	5/14/19	6/26/19	2 - Minimal harm or potential for actual harm	Some
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	5/14/19	6/26/19	4 - Immediate jeopardy to resident health or safety	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	6/22/22	7/28/22	2 - Minimal harm or potential for actual harm	Some

Resident Assessment and Care Planning Deficiencies
No Resident Assessment and Care Planning Deficiencies were found during this inspection period.

Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.	5/14/19	6/26/19	1 - Potential for minimal harm	Some

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.	5/14/19	6/26/19	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	5/14/19	6/26/19	2 - Minimal harm or potential for actual harm	Many

Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	8/28/24	9/10/24	2 - Minimal harm or potential for actual harm	Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	8/28/24	9/10/24	2 - Minimal harm or potential for actual harm	Few
Provide and implement an infection prevention and control program.	12/6/23	12/26/23	4 - Immediate jeopardy to resident health or safety	Many
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	7/31/23	8/1/23	2 - Minimal harm or potential for actual harm	Few
Protect each resident from the wrongful use of the resident's belongings or money.	11/16/22	12/5/22	2 - Minimal harm or potential for actual harm	Some
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	11/16/22	12/5/22	2 - Minimal harm or potential for actual harm	Few
Provide and implement an infection prevention and control program.	6/22/22	7/28/22	2 - Minimal harm or potential for actual harm	Some

Infection control inspection deficiencies in the past 3 years
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	12/6/23	12/26/23	4 - Immediate jeopardy to resident health or safety	Many
Provide and implement an infection prevention and control program.	6/22/22	7/28/22	2 - Minimal harm or potential for actual harm	Some

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