Deficiency Records for Legacy Transitional Care and Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for Legacy Transitional Care and Rehabilitation. 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? |
|---|---|---|---|---|
| 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 | 2023-10-13 | 2023-11-27 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-13 | 2023-11-27 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-10 | 2023-11-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-10 | 2023-11-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-10-10 | 2023-11-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-10 | 2023-11-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-10 | 2023-11-27 | 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 | 2023-08-10 | 2023-09-05 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-08-10 | 2023-09-05 | 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 | 2023-06-16 | 2023-07-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-16 | 2023-07-19 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-06-16 | 2023-07-19 | Y |
| Dispose of garbage and refuse properly. | Health | 2023-06-16 | 2023-07-19 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-06-16 | 2023-07-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-24 | 2022-11-04 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-09-24 | 2022-11-04 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-09-24 | 2022-11-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-24 | 2022-11-04 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-09-24 | 2022-11-04 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-09-24 | 2022-11-04 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-09-24 | 2022-11-04 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-09-24 | 2022-11-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-24 | 2022-11-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-24 | 2022-11-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-24 | 2022-11-04 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-09-24 | 2022-11-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-23 | 2021-09-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-23 | 2021-09-10 | Y |
| Meet other general requirements. | Fire Safety | 2018-12-10 | 2019-03-15 | 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 | 2018-12-10 | 2019-03-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-12-10 | 2019-03-15 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2018-12-10 | 2019-03-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-13 | 2019-01-27 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-12-13 | 2019-01-27 | N |
| Install proper backup exit lighting. | Fire Safety | 2018-12-10 | 2019-01-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-12-10 | 2019-01-27 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2018-12-10 | 2019-01-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-10 | 2019-01-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-12-10 | 2019-01-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-12-10 | 2019-01-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-12-10 | 2019-01-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-12-10 | 2019-01-27 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2018-12-10 | 2019-01-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-12-10 | 2019-01-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-12-10 | 2019-01-27 | N |
