Deficiency Records for Legacy at Herington
Updated as of March 01, 2021
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? |
---|---|---|---|---|
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 | Y |
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 | Y |
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 |
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 necessary and PRN use is limited. | 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 |