Deficiency Records for Legacy Health and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Legacy Health and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-06-21 | 2023-07-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-02 | 2023-07-02 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-03-09 | 2023-04-07 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-30 | 2023-02-07 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-12-30 | 2023-02-07 | N |
| 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. | Health | 2022-12-30 | 2023-02-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-30 | 2023-02-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-30 | 2023-02-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-30 | 2023-02-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-30 | 2023-02-07 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-12-30 | 2023-02-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-30 | 2023-02-07 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-12-30 | 2023-02-07 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-12-30 | 2023-02-07 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-12-30 | 2023-02-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-30 | 2023-02-07 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-12-30 | 2023-02-07 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-12-27 | 2023-02-07 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-12-27 | 2023-02-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-27 | 2023-02-07 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-12-27 | 2023-02-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-27 | 2023-02-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-12-27 | 2023-02-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-02 | 2023-02-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-16 | 2022-12-16 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-10-12 | 2022-10-12 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-02 | 2022-06-03 | Y |
| 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. | Health | 2022-02-15 | 2022-03-17 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-02-15 | 2022-03-17 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-02-15 | 2022-03-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-01 | 2021-09-29 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-08-10 | 2021-09-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-08-10 | 2021-09-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-10 | 2021-09-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-10 | 2021-09-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-10 | 2021-09-08 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-08-10 | 2021-09-08 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-08-10 | 2021-09-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-10 | 2021-09-08 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-08-10 | 2021-09-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-10 | 2021-09-08 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-08-10 | 2021-09-08 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-08-02 | 2021-09-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-02 | 2021-09-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-08-02 | 2021-09-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-01 | 2021-07-15 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-02-21 | 2020-03-16 | N |
| Assess the resident when there is a significant change in condition | Health | 2020-02-21 | 2020-03-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-21 | 2020-03-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-21 | 2020-03-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-02-21 | 2020-03-16 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-02-21 | 2020-03-16 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2020-02-21 | 2020-03-16 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2020-02-21 | 2020-03-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-21 | 2020-03-16 | N |
| Install proper backup exit lighting. | Fire Safety | 2020-02-20 | 2020-03-16 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-02-20 | 2020-03-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-20 | 2020-03-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-02-20 | 2020-03-16 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2020-02-21 | 2020-02-21 | N |
| 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. | Health | 2020-02-21 | 2020-02-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-02-21 | 2020-02-21 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2020-02-21 | 2020-02-21 | N |
