Deficiency Records for Legacy On 10th Avenue
Updated as of January 01, 2023
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? |
|---|---|---|---|---|
| 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 |
| 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 |
| 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 |
