Deficiency Records for Legacy Manor Nursing and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Legacy Manor Nursing and Rehabilitation. 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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2023-06-29 | 2023-07-28 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-08 | 2023-03-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-09 | 2023-03-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-09 | 2023-03-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-09 | 2023-03-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-02-09 | 2023-03-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-09 | 2023-03-10 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-08-15 | 2019-09-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-15 | 2019-09-23 | 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 | 2019-08-15 | 2019-09-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-15 | 2019-09-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-08-15 | 2019-09-23 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-08-15 | 2019-09-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-08-13 | 2019-09-23 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2018-09-20 | 2018-10-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-09-20 | 2018-10-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-09-20 | 2018-10-20 | 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 | 2018-09-20 | 2018-10-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-09-20 | 2018-10-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-20 | 2018-10-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-09-20 | 2018-10-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-20 | 2018-10-20 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2018-09-20 | 2018-10-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-20 | 2018-10-20 | N |
| Provide rooms that can be unlocked from inside without a key. | Fire Safety | 2018-09-18 | 2018-10-20 | N |
| Provide large enough exits. | Fire Safety | 2018-09-18 | 2018-10-20 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2018-09-18 | 2018-10-20 | N |
