Deficiency Records for Legendary Nursing and Rehabilitation LLC
Updated as of March 01, 2024
A list of the most recent deficiencies for Legendary Nursing and Rehabilitation LLC. 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 | 2023-11-16 | 2023-12-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-11 | 2023-12-14 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-08-11 | 2023-11-16 | 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 | 2023-08-11 | 2023-11-03 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-08-11 | 2023-11-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-11 | 2023-11-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-11 | 2023-09-25 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-08-11 | 2023-09-25 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2023-08-11 | 2023-09-25 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-08-11 | 2023-09-25 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-08-11 | 2023-09-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-11 | 2023-09-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-11 | 2023-09-25 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-08-11 | 2023-09-25 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-08-11 | 2023-09-25 | 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 | 2023-08-11 | 2023-09-25 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-08-11 | 2023-09-25 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-08-11 | 2023-09-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-11 | 2023-09-25 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-08-11 | 2023-09-25 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-08-11 | 2023-09-25 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-11 | 2023-09-25 | N |
| Use approved construction type or materials. | Fire Safety | 2023-08-11 | 2023-09-25 | 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 | 2023-08-11 | 2023-09-25 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-08-11 | 2023-09-25 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-11 | 2023-09-25 | 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 | 2023-08-11 | 2023-09-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-11 | 2023-09-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-11 | 2023-09-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-11 | 2023-09-25 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-08-11 | 2023-09-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-11 | 2023-09-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-11 | 2023-09-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-11 | 2023-09-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-11 | 2023-09-25 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-08-11 | 2023-09-25 | N |
| Meet other general requirements. | Fire Safety | 2023-08-11 | 2023-09-25 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2021-06-17 | 2021-09-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-05 | 2021-09-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-05 | 2021-09-09 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-17 | 2021-07-27 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-12-03 | 2020-01-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-03 | 2020-01-17 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-12-03 | 2020-01-17 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-12-03 | 2020-01-17 | 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 | 2019-12-03 | 2020-01-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-03 | 2020-01-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-12-03 | 2020-01-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-12-03 | 2020-01-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-03 | 2020-01-17 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2019-01-18 | 2019-03-04 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2019-01-18 | 2019-03-04 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-01-18 | 2019-03-04 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2019-01-18 | 2019-03-04 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-01-18 | 2019-03-04 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-01-18 | 2019-03-04 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-01-18 | 2019-03-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-01-18 | 2019-03-04 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2019-01-18 | 2019-03-04 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-01-18 | 2019-03-04 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-01-18 | 2019-03-04 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-01-18 | 2019-03-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-18 | 2019-03-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-18 | 2019-03-04 | N |
| Use approved construction type or materials. | Fire Safety | 2019-01-18 | 2019-03-04 | 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 | 2019-01-18 | 2019-03-04 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-01-18 | 2019-03-04 | 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 | 2019-01-18 | 2019-03-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-18 | 2019-03-04 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-01-18 | 2019-03-04 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-01-18 | 2019-03-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-01-18 | 2019-03-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-01-18 | 2019-03-04 | N |
| Meet other general requirements. | Fire Safety | 2019-01-18 | 2019-03-04 | N |
