A list of the most recent deficiencies for Legacy Westerville. 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 a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-06 | 2023-12-14 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-12-06 | 2023-12-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-06 | 2023-12-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-06 | 2023-12-14 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-10-10 | 2023-12-14 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-10-10 | 2023-12-14 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-10-10 | 2023-12-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-10 | 2023-12-14 | 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 | 2023-10-10 | 2023-12-14 | N |
| Provide activities to meet all resident's needs. | Health | 2023-10-10 | 2023-12-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-10 | 2023-12-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-10 | 2023-12-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-10 | 2023-12-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-10-10 | 2023-12-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-10-10 | 2023-12-14 | 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 | 2023-10-10 | 2023-12-14 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-10-10 | 2023-12-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-10 | 2023-12-14 | Y |
| 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 | 2023-10-10 | 2023-12-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-10 | 2023-12-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-10-10 | 2023-12-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-10 | 2023-12-14 | Y |
| 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 | 2023-10-10 | 2023-12-14 | Y |
| Construct fire resistant interior walls. | Fire Safety | 2023-10-02 | 2023-12-14 | N |
| Provide outside doors or windows in every resident room. | Fire Safety | 2023-10-02 | 2023-12-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-10-02 | 2023-12-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-10 | 2023-06-02 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-05-10 | 2023-06-02 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-05-10 | 2023-06-02 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-10 | 2023-06-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-21 | 2023-02-24 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-01-23 | 2023-02-24 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-23 | 2023-02-24 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-23 | 2023-02-24 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-01-23 | 2023-02-24 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-01 | 2023-02-24 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-01 | 2023-02-24 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-12-01 | 2023-02-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-01 | 2023-02-24 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-08-30 | 2022-09-29 | 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 | 2022-08-30 | 2022-09-29 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-04-20 | 2022-04-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-16 | 2021-12-16 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-10-05 | 2021-11-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-05 | 2021-11-16 | N |
| Provide activities to meet all resident's needs. | Health | 2021-10-05 | 2021-11-16 | 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 | 2021-10-05 | 2021-11-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-05 | 2021-11-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-10-05 | 2021-11-16 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-10-05 | 2021-11-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-05 | 2021-11-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-05 | 2021-11-16 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-10-05 | 2021-11-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-05 | 2021-11-16 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-18 | 2021-11-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-01 | 2021-07-05 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-06-13 | 2019-07-16 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-06-13 | 2019-07-16 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-06-13 | 2019-07-16 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-06-13 | 2019-07-16 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2019-06-13 | 2019-07-16 | 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 | 2019-06-13 | 2019-07-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-13 | 2019-07-16 | 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 | 2019-06-13 | 2019-07-16 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-06-13 | 2019-07-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-06-13 | 2019-07-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-06-13 | 2019-07-16 | 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 | 2019-06-13 | 2019-07-16 | 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 | 2019-06-13 | 2019-07-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-13 | 2019-07-16 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-06-13 | 2019-07-16 | N |
| Keep all essential equipment working safely. | Health | 2019-06-13 | 2019-07-16 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-06-10 | 2019-07-16 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-06-10 | 2019-07-16 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-06-10 | 2019-07-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-06-10 | 2019-07-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-10 | 2019-07-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-10 | 2019-07-16 | N |
