Deficiency Records for Legendary Nursing and Rehabilitation LLC
Updated as of January 01, 2022
This is not the most recent data for Legendary Nursing and Rehabilitation LLC. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2020-10-01 | 2020-11-13 | Y |
| 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 | 2020-10-01 | 2020-11-13 | 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 |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2017-12-21 | 2018-01-12 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2017-12-21 | 2018-01-12 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2017-12-21 | 2018-01-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2017-12-21 | 2018-01-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2017-12-21 | 2018-01-12 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2017-12-21 | 2018-01-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2017-12-21 | 2018-01-12 | 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 | 2017-12-21 | 2018-01-12 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2017-12-21 | 2018-01-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2017-12-21 | 2018-01-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2017-12-21 | 2018-01-12 | 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 | 2017-12-21 | 2018-01-12 | 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 | 2017-12-21 | 2018-01-12 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2017-12-21 | 2018-01-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-12-21 | 2018-01-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-12-21 | 2018-01-12 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2017-12-21 | 2018-01-12 | N |
