A list of the most recent deficiencies for Legacy Willoughby. 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? |
|---|---|---|---|---|
| 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 | 2023-08-01 | 2023-08-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-01 | 2023-08-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-01 | 2023-08-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-03 | 2023-07-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-01 | 2023-05-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-01 | 2023-05-12 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-01 | 2023-05-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-14 | 2022-07-08 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-06-14 | 2022-07-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-14 | 2022-07-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-09 | 2021-08-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-09 | 2021-08-09 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-07-09 | 2021-08-09 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-05-07 | 2021-08-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-07 | 2021-08-09 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-11-21 | 2019-12-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-11-19 | 2019-12-10 | N |
| Honor the resident's right to choose his or her attending physician. | Health | 2018-10-04 | 2018-11-27 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-10-04 | 2018-11-27 | 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 | 2018-10-04 | 2018-11-27 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-10-04 | 2018-11-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-10-04 | 2018-11-27 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-10-04 | 2018-11-27 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-10-02 | 2018-11-27 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2018-10-02 | 2018-11-27 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-10-02 | 2018-11-27 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-10-02 | 2018-11-27 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-10-02 | 2018-11-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-10-02 | 2018-11-27 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-10-02 | 2018-11-27 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2018-10-02 | 2018-11-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-02 | 2018-11-27 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2018-10-02 | 2018-11-27 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2018-10-02 | 2018-11-27 | N |
