Deficiency Records for Legacy Heights Nursing and Rehab, LLC
Updated as of March 01, 2024
A list of the most recent deficiencies for Legacy Heights Nursing and Rehab, LLC. 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? |
|---|---|---|---|---|
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-01-20 | 2023-02-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-20 | 2023-02-19 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2023-01-20 | 2023-02-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-29 | 2022-10-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-29 | 2022-10-21 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-04 | 2022-04-03 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-11-18 | 2021-12-18 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-11-18 | 2021-12-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-18 | 2021-12-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-09-29 | 2020-10-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-09-29 | 2020-10-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-09-29 | 2020-10-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-09-29 | 2020-10-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-09-29 | 2020-10-28 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2020-09-29 | 2020-10-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-09-29 | 2020-10-28 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-09-29 | 2020-10-28 | 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 | 2020-09-29 | 2020-10-28 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2020-09-29 | 2020-10-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-09-29 | 2020-10-28 | N |
| Dispose of garbage and refuse properly. | Health | 2020-09-29 | 2020-10-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-09-29 | 2020-10-28 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2020-09-21 | 2020-10-28 | N |
| Install proper backup exit lighting. | Fire Safety | 2020-09-21 | 2020-10-28 | 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 | 2020-09-21 | 2020-10-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-09-21 | 2020-10-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-09-21 | 2020-10-28 | N |
