A list of the most recent deficiencies for Legacy at Salina. 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? |
|---|---|---|---|---|
| Use approved construction type or materials. | Fire Safety | 2024-02-13 | 2024-03-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-02-13 | 2024-03-14 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-02-13 | 2024-03-14 | 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 | 2024-02-13 | 2024-03-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-13 | 2024-03-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-13 | 2024-03-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-13 | 2024-03-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-13 | 2024-03-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-02-13 | 2024-03-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-13 | 2024-03-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-21 | 2022-12-13 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-07-12 | 2022-08-01 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-07-12 | 2022-08-01 | 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 | 2022-07-12 | 2022-08-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-07-12 | 2022-08-01 | 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 | 2022-07-12 | 2022-08-01 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-07-12 | 2022-08-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-12 | 2022-08-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-07-12 | 2022-08-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-07-12 | 2022-08-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-07-12 | 2022-08-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-07-12 | 2022-08-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-12 | 2022-08-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-07-12 | 2022-08-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-26 | 2022-07-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-26 | 2022-07-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-26 | 2022-07-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-26 | 2022-06-15 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-05-26 | 2022-06-15 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-05-26 | 2022-06-15 | N |
| Provide activities to meet all resident's needs. | Health | 2022-05-26 | 2022-06-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-26 | 2022-06-15 | N |
| 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 | 2022-05-26 | 2022-06-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-05-26 | 2022-06-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-05-26 | 2022-06-15 | N |
| Post nurse staffing information every day. | Health | 2022-05-26 | 2022-06-15 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-05-26 | 2022-06-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-05-26 | 2022-06-15 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-05-26 | 2022-06-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-26 | 2022-06-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-26 | 2022-06-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-12-08 | 2021-01-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-12-08 | 2021-01-15 | 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 | 2020-12-08 | 2021-01-15 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2020-12-08 | 2021-01-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-12-08 | 2021-01-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-12-08 | 2021-01-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-12-08 | 2021-01-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-12-08 | 2021-01-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-12-08 | 2021-01-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-12-08 | 2021-01-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-12-08 | 2021-01-15 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-10-22 | 2020-11-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-10-22 | 2020-11-05 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-01-08 | Not Fixed | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-01-08 | Not Fixed | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-01-08 | Not Fixed | 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 | 2024-01-08 | Not Fixed | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-08 | Not Fixed | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-08 | Not Fixed | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-08 | Not Fixed | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-01-08 | Not Fixed | 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 | 2024-01-08 | Not Fixed | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-01-08 | Not Fixed | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-08 | Not Fixed | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-08 | Not Fixed | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2024-01-08 | Not Fixed | N |
