A list of the most recent deficiencies for Legend Healthcare. 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 treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-31 | 2023-08-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-08 | 2023-06-10 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-07 | 2022-10-21 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-09-07 | 2022-10-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-07 | 2022-10-21 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-09-07 | 2022-10-21 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-09-07 | 2022-10-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-07 | 2022-10-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-07 | 2022-10-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-07 | 2022-10-21 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-07 | 2022-10-21 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-09-07 | 2022-10-21 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-09-07 | 2022-10-21 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-07 | 2022-10-21 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-09-07 | 2022-10-21 | Y |
| 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 | 2022-09-07 | 2022-10-21 | Y |
| 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 | 2022-09-07 | 2022-10-21 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-07 | 2022-10-21 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-09-07 | 2022-10-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-07 | 2022-10-21 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-09-07 | 2022-10-21 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-09-07 | 2022-10-21 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-09-07 | 2022-10-21 | Y |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-09-13 | 2022-10-13 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-09-13 | 2022-10-13 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-09-13 | 2022-10-13 | N |
| Meet other general requirements. | Fire Safety | 2022-09-13 | 2022-10-13 | N |
| Use approved construction type or materials. | Fire Safety | 2022-09-13 | 2022-10-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-09-13 | 2022-10-13 | 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 | 2022-09-13 | 2022-10-13 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-09-13 | 2022-10-13 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-09-13 | 2022-10-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-09-13 | 2022-10-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-13 | 2022-10-13 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-09-13 | 2022-10-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-09-13 | 2022-10-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-09-13 | 2022-10-13 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-09-13 | 2022-10-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-13 | 2022-10-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-09-13 | 2022-10-13 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2022-09-13 | 2022-10-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-09-13 | 2022-10-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-13 | 2022-10-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-13 | 2022-10-13 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-03-11 | 2021-03-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-11 | 2021-03-26 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-03-11 | 2021-03-26 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-03-11 | 2021-03-26 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-03-11 | 2021-03-26 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-03-03 | 2020-03-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-03-03 | 2020-03-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-03-03 | 2020-03-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-03-03 | 2020-03-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-03-03 | 2020-03-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-03-03 | 2020-03-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-03-03 | 2020-03-31 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-03-03 | 2020-03-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-03-03 | 2020-03-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-03-03 | 2020-03-31 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-04-03 | 2019-06-20 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-04-03 | 2019-06-20 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-04-03 | 2019-06-20 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-04-03 | 2019-06-20 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-04-03 | 2019-06-20 | N |
| Develop a communication plan. | Fire Safety | 2019-04-03 | 2019-06-20 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-04-03 | 2019-06-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-04-03 | 2019-06-20 | 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 | 2019-04-03 | 2019-06-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-04-03 | 2019-06-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-04-03 | 2019-06-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-03 | 2019-06-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-04-03 | 2019-06-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-04-03 | 2019-06-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-04-03 | 2019-06-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-04-03 | 2019-06-20 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-04-03 | 2019-06-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-03 | 2019-06-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-03 | 2019-06-20 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-04-08 | 2019-05-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-08 | 2019-05-01 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-04-08 | 2019-05-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-08 | 2019-05-01 | 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 | 2019-04-08 | 2019-05-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-04-08 | 2019-05-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-04-08 | 2019-05-01 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-04-08 | 2019-05-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-04-08 | 2019-05-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-04-08 | 2019-05-01 | 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 | 2019-04-08 | 2019-05-01 | 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 | 2019-04-08 | 2019-05-01 | 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 | 2019-04-08 | 2019-05-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-08 | 2019-05-01 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-04-08 | 2019-05-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-04-08 | 2019-05-01 | N |
