CONTACT INFORMATION REVIEWS & MORE DATA
Deficiency Records for Legacy at Herington
View the most recent health deficiencies and inspection results for Legacy at Herington. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Legacy at Herington. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-03-28 | 2025-04-10 | Y |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2025-03-28 | 2025-04-10 | Y |
| Meet other general requirements. | Fire Safety | 2024-10-31 | 2024-12-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-10-31 | 2024-12-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-10-31 | 2024-12-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-10-31 | 2024-12-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-10-31 | 2024-12-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-10-31 | 2024-12-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-10-31 | 2024-12-19 | 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 | 2024-10-31 | 2024-12-19 | N |
| Use approved construction type or materials. | Fire Safety | 2024-10-31 | 2024-12-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-10-31 | 2024-12-19 | 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 | 2024-10-31 | 2024-12-19 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-10-31 | 2024-12-19 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-10-31 | 2024-12-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-10-31 | 2024-12-16 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2024-10-31 | 2024-12-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-10-31 | 2024-12-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-10-31 | 2024-12-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-10-31 | 2024-12-16 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-10-31 | 2024-12-16 | N |
| Construct fire resistant interior walls. | Fire Safety | 2024-10-31 | 2024-12-16 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-10-31 | 2024-11-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-10-31 | 2024-11-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-10-31 | 2024-11-17 | 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 | 2024-10-31 | 2024-11-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-10-31 | 2024-11-17 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-10-31 | 2024-11-17 | N |
| Post nurse staffing information every day. | Health | 2024-10-31 | 2024-11-17 | 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 | 2024-10-31 | 2024-11-17 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-10-31 | 2024-11-17 | 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 | 2024-10-31 | 2024-11-17 | 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 | 2024-10-31 | 2024-11-17 | 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 | 2024-10-31 | 2024-11-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-10-31 | 2024-11-17 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-10-31 | 2024-11-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-04-03 | 2024-04-18 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2024-04-03 | 2024-04-18 | Y |
| Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. | Health | 2024-04-03 | 2024-04-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-20 | 2023-10-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-20 | 2023-10-09 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-22 | 2023-07-17 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-22 | 2023-07-17 | N |
| Meet other general requirements. | Fire Safety | 2023-05-22 | 2023-07-17 | N |
| Use approved construction type or materials. | Fire Safety | 2023-05-22 | 2023-07-17 | 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 | 2023-05-22 | 2023-07-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-22 | 2023-07-17 | 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 | 2023-05-22 | 2023-07-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-22 | 2023-07-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-22 | 2023-07-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-22 | 2023-07-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-22 | 2023-07-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-22 | 2023-07-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-22 | 2023-07-17 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-05-22 | 2023-07-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-22 | 2023-07-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-05-22 | 2023-07-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-22 | 2023-07-17 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-05-22 | 2023-07-05 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-22 | 2023-07-05 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-22 | 2023-07-05 | Y |
| 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 | 2023-05-22 | 2023-07-05 | Y |
| 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 | 2023-05-22 | 2023-07-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-22 | 2023-07-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-22 | 2023-07-05 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-05-22 | 2023-07-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-22 | 2023-07-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-22 | 2023-07-05 | Y |
| Keep signed and dated reports of x-rays and other diagnostic services in the residents record. | Health | 2023-05-22 | 2023-07-05 | 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 | 2023-05-22 | 2023-07-05 | N |
| 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 | 2023-05-22 | 2023-07-05 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-05-22 | 2023-07-05 | Y |
| Implement a program that monitors antibiotic use. | Health | 2023-05-22 | 2023-07-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-22 | 2023-07-05 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-05-22 | 2023-07-05 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-05-22 | 2023-07-05 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-05-22 | 2023-07-05 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-22 | 2023-07-05 | Y |
| 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 | 2023-05-22 | 2023-07-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-22 | 2023-04-24 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-09-27 | 2021-12-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-09-27 | 2021-12-20 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-09-27 | 2021-12-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-09-27 | 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 | 2021-09-27 | 2021-12-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-09-27 | 2021-12-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-09-27 | 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 | 2021-09-27 | 2021-12-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-27 | 2021-12-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-27 | 2021-12-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-09-27 | 2021-12-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-09-27 | 2021-12-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-09-27 | 2021-12-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-09-27 | 2021-12-20 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-09-27 | 2021-12-20 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-09-27 | 2021-10-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-27 | 2021-10-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-27 | 2021-10-08 | N |