Deficiency Records for Legacy at Herington
Updated as of May 01, 2019
This is not the most recent data for Legacy at Herington. For the most recent information, click here.
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 | 2019-01-30 | 2019-02-14 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-01-30 | 2019-02-14 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-01-30 | 2019-02-14 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-10-29 | 2018-11-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-10-29 | 2018-11-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-29 | 2018-11-21 | 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 | 2018-10-29 | 2018-11-21 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-10-29 | 2018-11-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-10-29 | 2018-11-21 | 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 | 2018-10-29 | 2018-11-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-29 | 2018-11-21 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-10-29 | 2018-11-21 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-10-29 | 2018-11-21 | 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 ne | Health | 2018-10-29 | 2018-11-21 | 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 | 2018-10-29 | 2018-11-21 | Y |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2018-10-29 | 2018-11-21 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-29 | 2018-11-21 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-10-29 | 2018-11-21 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-10-29 | 2018-11-21 | Y |
| Keep all essential equipment working safely. | Health | 2018-10-29 | 2018-11-21 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-10-29 | 2018-11-21 | Y |
| Put firmly secured handrails on each side of hallways. | Health | 2018-10-29 | 2018-11-21 | Y |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2018-04-06 | 2018-06-22 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-04-06 | 2018-06-22 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-04-06 | 2018-06-22 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2018-05-23 | 2018-06-08 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-05-23 | 2018-06-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-05-23 | 2018-06-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-05-23 | 2018-06-08 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-23 | 2018-06-08 | Y |
| Implement a program that monitors antibiotic use. | Health | 2018-05-23 | 2018-06-08 | Y |
| Give residents a notice of rights, rules, services and charges. | Health | 2017-03-28 | 2017-04-27 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2017-03-28 | 2017-04-27 | N |
| Provide housekeeping and maintenance services. | Health | 2017-03-28 | 2017-04-27 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-03-28 | 2017-04-27 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-03-28 | 2017-04-27 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-03-28 | 2017-04-27 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-03-28 | 2017-04-27 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-03-28 | 2017-04-27 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-03-28 | 2017-04-27 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-03-28 | 2017-04-27 | N |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2016-11-02 | 2017-02-23 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2016-11-02 | 2017-02-23 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-11-02 | 2017-02-23 | Y |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2016-11-02 | 2017-02-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-11-02 | 2017-02-23 | Y |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-11-02 | 2017-02-23 | Y |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2016-11-02 | 2017-02-23 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2016-11-02 | 2017-02-23 | Y |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-01-25 | 2017-01-30 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-11-02 | 2016-11-03 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-11-02 | 2016-11-03 | Y |
| Use a registered nurse at least 8 hours a day, 7 days a week. | Health | 2016-11-02 | 2016-11-03 | Y |
| Protect each resident from mistreatment, neglect and misappropriation of personal property. | Health | 2015-06-12 | 2015-07-10 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2015-06-12 | 2015-07-10 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2015-06-12 | 2015-07-10 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2015-06-12 | 2015-07-10 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2015-06-12 | 2015-07-10 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2015-06-12 | 2015-07-10 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2015-06-12 | 2015-07-10 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2015-06-12 | 2015-07-10 | N |
| Ensure that residents are safe from serious medication errors. | Health | 2015-06-12 | 2015-07-10 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2015-06-12 | 2015-07-10 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2015-06-12 | 2015-07-10 | N |
