Deficiency Records for Legacy On 10th Avenue
Updated as of June 01, 2018
This is not the most recent data for Legacy On 10th Avenue. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-08-16 | 2017-08-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-06-29 | 2017-06-29 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-04-26 | 2017-05-15 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2017-04-26 | 2017-05-15 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2017-04-26 | 2017-05-15 | Y |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2017-04-26 | 2017-05-15 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-04-26 | 2017-05-15 | Y |
| Provide housekeeping and maintenance services. | Health | 2017-04-26 | 2017-05-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-04-26 | 2017-05-15 | Y |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-04-26 | 2017-05-15 | Y |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2017-04-26 | 2017-05-15 | Y |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-04-26 | 2017-05-15 | Y |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-04-26 | 2017-05-15 | Y |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2017-04-26 | 2017-05-15 | Y |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2016-11-02 | 2016-11-21 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2016-11-02 | 2016-11-21 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-11-02 | 2016-11-21 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-10-19 | 2016-11-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-10-19 | 2016-11-16 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2016-10-19 | 2016-11-16 | Y |
| Exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2016-09-16 | 2016-09-23 | N |
| Exits that are accessible at all times. | Fire Safety | 2016-09-16 | 2016-09-23 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2015-12-31 | 2016-01-29 | Y |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2015-12-31 | 2016-01-29 | Y |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2015-12-31 | 2016-01-29 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2015-09-09 | 2015-10-09 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2015-09-09 | 2015-10-09 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2015-09-09 | 2015-10-09 | Y |
| Send unopened mail from residents and promptly deliver unopened mail to residents. | Health | 2015-09-09 | 2015-10-09 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2015-09-09 | 2015-10-09 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2015-09-09 | 2015-10-09 | Y |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2015-09-09 | 2015-10-09 | Y |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2015-09-09 | 2015-10-09 | Y |
| Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. | Health | 2015-09-09 | 2015-10-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2015-09-09 | 2015-10-09 | Y |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2015-09-09 | 2015-10-09 | Y |
| Develop policies and procedures for influenza and pneumococcal immunizations. | Health | 2015-09-09 | 2015-10-09 | Y |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2015-09-09 | 2015-10-09 | Y |
| Store, cook, and serve food in a safe and clean way. | Health | 2015-09-09 | 2015-10-09 | Y |
| Make sure that doctors visit residents regularly, as required. | Health | 2015-09-09 | 2015-10-09 | Y |
| Provide or obtain dental services for each resident. | Health | 2015-09-09 | 2015-10-09 | Y |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2015-09-09 | 2015-10-09 | Y |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2015-09-09 | 2015-10-09 | Y |
| Make sure that a working call system is available in each resident's room or bathroom and bathing area. | Health | 2015-09-09 | 2015-10-09 | Y |
| 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. | Health | 2015-09-09 | 2015-10-09 | Y |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2015-09-09 | 2015-10-09 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2015-06-23 | 2015-07-23 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2015-06-23 | 2015-07-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2015-06-23 | 2015-07-23 | Y |
| Approved construction type or materials. | Fire Safety | 2015-05-18 | 2015-06-16 | N |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2015-05-18 | 2015-06-16 | N |
| Corridor and hallway doors that block smoke. | Fire Safety | 2015-05-18 | 2015-06-12 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2015-05-18 | 2015-06-12 | N |
| Exits that are accessible at all times. | Fire Safety | 2015-05-18 | 2015-06-11 | N |
| Emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2015-05-18 | 2015-06-09 | N |
| Record of quarterly fire drills for each shift under varying conditions. | Fire Safety | 2015-05-18 | 2015-06-09 | N |
| An approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2015-05-18 | 2015-06-09 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2015-05-18 | 2015-06-03 | N |
| Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2015-05-18 | 2015-05-20 | N |
| Proper medical gas storage and administration areas. | Fire Safety | 2015-05-18 | 2015-05-20 | N |
| Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. | Health | 2014-05-21 | 2014-08-07 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2014-05-21 | 2014-08-07 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2014-05-21 | 2014-08-07 | N |
| Provide housekeeping and maintenance services. | Health | 2014-05-21 | 2014-08-07 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2014-05-21 | 2014-08-07 | N |
| Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves. | Health | 2014-05-21 | 2014-08-07 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2014-05-21 | 2014-08-07 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2014-05-21 | 2014-08-07 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2014-05-21 | 2014-08-07 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2014-05-21 | 2014-08-07 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2014-05-21 | 2014-08-07 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2014-05-21 | 2014-07-17 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2014-05-21 | 2014-07-17 | N |
| Upon the death of a resident, convey the resident?s personal funds and an accounting of those funds to the appropriate party. | Health | 2014-05-21 | 2014-07-17 | N |
| Provide proof that residents' personal money that is deposited with the nursing home is secure. | Health | 2014-05-21 | 2014-07-17 | N |
| Try to resolve each resident's complaints quickly. | Health | 2014-05-21 | 2014-07-17 | N |
| Allow residents to easily view the results of the nursing home's most recent inspection. | Health | 2014-05-21 | 2014-07-17 | N |
| Review or revise the resident's care plan after any major change in physical or mental health. | Health | 2014-05-21 | 2014-07-17 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2014-05-21 | 2014-07-17 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2014-05-21 | 2014-07-17 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2014-05-21 | 2014-07-17 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2014-05-21 | 2014-07-17 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2014-05-21 | 2014-07-17 | N |
| Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. | Health | 2014-05-21 | 2014-07-17 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2014-05-21 | 2014-07-17 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2014-05-21 | 2014-07-17 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2014-05-21 | 2014-07-17 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2014-05-21 | 2014-07-17 | N |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2014-05-21 | 2014-07-17 | N |
| Use a registered nurse at least 8 hours a day, 7 days a week. | Health | 2014-05-21 | 2014-07-17 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2014-05-21 | 2014-07-17 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2014-05-21 | 2014-07-17 | N |
| Give or get specialized rehabilitative services per the patient's assessment or plan of care. | Health | 2014-05-21 | 2014-07-17 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2014-05-21 | 2014-07-17 | N |
| Keep all essential equipment working safely. | Health | 2014-05-21 | 2014-07-17 | N |
| Make sure that a working call system is available in each resident's room or bathroom and bathing area. | Health | 2014-05-21 | 2014-07-17 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2014-05-21 | 2014-07-17 | N |
| Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . | Health | 2014-05-21 | 2014-07-17 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2014-05-21 | 2014-07-17 | N |
