Deficiency Records for Legacy at Herington
Updated as of May 01, 2022
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 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 |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-02-24 | 2021-02-25 | Y |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-02-24 | 2021-02-25 | 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 | 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 |
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 |
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 | N |
Respond appropriately to all alleged violations. | Health | 2018-10-29 | 2018-11-21 | N |
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 | 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 | 2018-10-29 | 2018-11-21 | N |
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 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-10-29 | 2018-11-21 | 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 | 2018-10-29 | 2018-11-21 | N |
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 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2018-10-29 | 2018-11-21 | N |
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 | 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 | 2018-10-29 | 2018-11-21 | 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 | 2018-10-29 | 2018-11-21 | N |
Provide routine and 24-hour emergency dental care for each resident. | Health | 2018-10-29 | 2018-11-21 | N |
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 | N |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-10-29 | 2018-11-21 | N |
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 | N |
Keep all essential equipment working safely. | Health | 2018-10-29 | 2018-11-21 | N |
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 | N |
Put firmly secured handrails on each side of hallways. | Health | 2018-10-29 | 2018-11-21 | N |
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 |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-04-06 | 2018-06-22 | N |
Provide properly protected cooking facilities. | Fire Safety | 2018-04-06 | 2018-06-22 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-04-06 | 2018-06-22 | N |
Provide a written emergency evacuation plan. | Fire Safety | 2018-04-06 | 2018-06-22 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2018-04-06 | 2018-06-22 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2018-04-06 | 2018-06-22 | N |