A list of the most recent deficiencies for Legacy at Herington. 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? |
|---|---|---|---|---|
| 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 |
| Conduct testing and exercise requirements. | Fire Safety | 2023-06-06 | 2023-07-17 | N |
| Meet other general requirements. | Fire Safety | 2023-06-06 | 2023-07-17 | N |
| Use approved construction type or materials. | Fire Safety | 2023-06-06 | 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 | 2023-06-06 | 2023-07-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-06-06 | 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 | 2023-06-06 | 2023-07-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-06 | 2023-07-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-06 | 2023-07-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-06 | 2023-07-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-06-06 | 2023-07-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-06 | 2023-07-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-06-06 | 2023-07-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-06 | 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 | 2023-06-06 | 2023-07-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-06 | 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 | 2023-06-06 | 2023-07-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-06 | 2023-07-17 | 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 | 2023-05-22 | 2023-07-05 | N |
| Keep signed and dated reports of x-rays and other diagnostic services in the residents record. | Health | 2023-05-22 | 2023-07-05 | N |
| 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 |
| 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 |
| 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 |
| 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 appropriate pressure ulcer care and prevent new ulcers from developing. | 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 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 enough food/fluids to maintain a resident's health. | 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 |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | 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 |
| 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 |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | 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 |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | 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 |
| Implement a program that monitors antibiotic use. | 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 |
| 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 |
| 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 |
| Keep residents' personal and medical records private and confidential. | Health | 2023-03-01 | 2023-03-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-19 | 2022-01-28 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-11-02 | 2021-12-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-11-02 | 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 | 2021-11-02 | 2021-12-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-11-02 | 2021-12-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-11-02 | 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 | 2021-11-02 | 2021-12-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-11-02 | 2021-12-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-02 | 2021-12-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-11-02 | 2021-12-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-02 | 2021-12-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-11-02 | 2021-12-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-11-02 | 2021-12-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-02 | 2021-12-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-11-02 | 2021-12-20 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-11-02 | 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 |
| 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 | 2019-08-07 | 2019-09-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-07 | 2019-09-06 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-07-17 | 2019-08-16 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-07-17 | 2019-08-16 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-07-17 | 2019-08-16 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-07-17 | 2019-08-16 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-07-17 | 2019-08-16 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-07-17 | 2019-08-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-07-17 | 2019-08-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-07-17 | 2019-08-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-07-17 | 2019-08-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-07-17 | 2019-08-16 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2019-07-17 | 2019-08-16 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-07-17 | 2019-08-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-17 | 2019-08-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-07-17 | 2019-08-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-17 | 2019-08-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-17 | 2019-08-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-17 | 2019-08-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-17 | 2019-07-17 | N |
