Deficiency Records for Legacy On 10th Avenue
Updated as of November 01, 2021
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 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 |
| Provide and implement an infection prevention and control program. | Health | 2020-11-09 | 2020-12-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-06-23 | 2020-08-05 | N |
| 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 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-10 | 2019-07-10 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-10-08 | 2018-11-07 | N |
| Dispose of garbage and refuse properly. | Health | 2018-10-08 | 2018-11-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-08 | 2018-11-07 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-10-08 | 2018-11-07 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-10-08 | 2018-11-07 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-10-08 | 2018-11-07 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-05-10 | 2018-06-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-05-10 | 2018-06-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-05-10 | 2018-06-14 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-05-10 | 2018-06-14 | 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 | 2018-05-10 | 2018-06-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-05-10 | 2018-06-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-05-10 | 2018-06-14 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-05-10 | 2018-06-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-05-10 | 2018-06-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-05-10 | 2018-06-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-05-10 | 2018-06-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-05-10 | 2018-06-14 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2017-04-26 | 2017-05-15 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2017-04-26 | 2017-05-15 | N |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2017-04-26 | 2017-05-15 | N |
| 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 | N |
| Provide housekeeping and maintenance services. | Health | 2017-04-26 | 2017-05-15 | N |
| 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 | 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 | 2017-04-26 | 2017-05-15 | N |
| 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 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-04-26 | 2017-05-15 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-04-26 | 2017-05-15 | N |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2017-04-26 | 2017-05-15 | N |
| 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 |
| Approved construction type or materials. | Fire Safety | 2016-09-16 | 2016-10-15 | N |
| Corridor and hallway doors that block smoke. | Fire Safety | 2016-09-16 | 2016-10-15 | N |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2016-09-16 | 2016-10-15 | N |
| Emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2016-09-16 | 2016-10-15 | N |
| Record of quarterly fire drills for each shift under varying conditions. | Fire Safety | 2016-09-16 | 2016-10-15 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2016-09-16 | 2016-10-15 | N |
| Posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2016-09-16 | 2016-10-15 | N |
| Exits that are free from obstructions and can be used at all times. | Fire Safety | 2016-09-16 | 2016-10-15 | N |
| Restrictions on the use of flammable curtains. | Fire Safety | 2016-09-16 | 2016-10-15 | N |
| Proper medical gas storage and administration areas. | Fire Safety | 2016-09-16 | 2016-10-15 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2016-09-16 | 2016-10-15 | N |
| 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 |
