A list of the most recent deficiencies for Legacy On 10th Avenue. 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? |
|---|---|---|---|---|
| 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 | 2023-10-25 | 2023-12-06 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2023-10-25 | 2023-12-06 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-10-02 | 2023-10-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-11 | 2023-08-04 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-07-11 | 2023-08-04 | Y |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-07-11 | 2023-08-04 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-04-18 | 2023-06-30 | 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 | 2023-04-18 | 2023-06-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-18 | 2023-06-30 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-05-11 | 2023-06-15 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-05-11 | 2023-06-15 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-05-11 | 2023-06-15 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-05-11 | 2023-06-15 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-05-11 | 2023-06-15 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-05-11 | 2023-06-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-05-11 | 2023-06-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-11 | 2023-06-15 | N |
| Use approved construction type or materials. | Fire Safety | 2023-05-11 | 2023-06-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-11 | 2023-06-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-11 | 2023-06-15 | 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 | 2023-05-11 | 2023-06-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-11 | 2023-06-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-11 | 2023-06-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-11 | 2023-06-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-05-11 | 2023-06-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-11 | 2023-06-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-05-11 | 2023-06-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-11 | 2023-06-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-11 | 2023-06-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-11 | 2023-06-15 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-05-11 | 2023-06-15 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-04-18 | 2023-05-22 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-04-18 | 2023-05-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-18 | 2023-05-22 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-04-18 | 2023-05-22 | N |
| 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 | 2023-04-18 | 2023-05-22 | 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 | 2023-04-18 | 2023-05-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-18 | 2023-05-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-18 | 2023-05-22 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-04-18 | 2023-05-22 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-04-18 | 2023-05-22 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-04-18 | 2023-05-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-01 | 2022-12-07 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-22 | 2022-09-09 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-11-17 | 2021-12-20 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-11-17 | 2021-12-20 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2021-11-17 | 2021-12-20 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-11-17 | 2021-12-20 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-11-17 | 2021-12-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-11-17 | 2021-12-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-11-17 | 2021-12-20 | 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 | 2021-11-17 | 2021-12-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-11-17 | 2021-12-20 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-11-17 | 2021-12-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-11-17 | 2021-12-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-17 | 2021-12-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-11-17 | 2021-12-20 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-11-17 | 2021-12-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-17 | 2021-12-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-11-17 | 2021-12-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-11-17 | 2021-12-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-17 | 2021-12-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-11-17 | 2021-12-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-11-17 | 2021-12-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-11-17 | 2021-12-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-11-17 | 2021-12-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-11-17 | 2021-12-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-25 | 2021-11-25 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-10-25 | 2021-11-25 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2021-10-25 | 2021-11-25 | 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 | 2021-10-25 | 2021-11-25 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-04-28 | 2021-04-27 | Y |
| 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 | 2021-03-02 | 2021-03-02 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-11-21 | 2019-12-21 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-11-21 | 2019-12-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-21 | 2019-12-21 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-10-15 | 2019-11-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-10-15 | 2019-11-15 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-10-15 | 2019-11-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-10-15 | 2019-11-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-15 | 2019-11-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-10-15 | 2019-11-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-10-15 | 2019-11-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-15 | 2019-11-15 | N |
