A list of the most recent deficiencies for Legacy Bucyrus. 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? |
|---|---|---|---|---|
| Address subsistence needs for staff and patients. | Fire Safety | 2024-02-12 | 2024-03-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-02-12 | 2024-03-06 | 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 | 2024-02-12 | 2024-03-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-02-12 | 2024-03-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-02-12 | 2024-03-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-02-12 | 2024-03-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-12 | 2024-03-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-02-12 | 2024-03-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-02-12 | 2024-03-06 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-02-15 | 2024-03-01 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-02-15 | 2024-03-01 | N |
| 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 | 2024-02-15 | 2024-03-01 | N |
| Respond appropriately to all alleged violations. | Health | 2024-02-15 | 2024-03-01 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-02-15 | 2024-03-01 | 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 | 2024-02-15 | 2024-03-01 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-02-15 | 2024-03-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-02-15 | 2024-03-01 | N |
| Post nurse staffing information every day. | Health | 2024-02-15 | 2024-03-01 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-02-15 | 2024-03-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-15 | 2024-03-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-15 | 2024-03-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-02-15 | 2024-03-01 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-02-15 | 2024-03-01 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2024-02-15 | 2024-03-01 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2024-02-15 | 2024-03-01 | Y |
| Provide activities to meet all resident's needs. | Health | 2024-02-15 | 2024-03-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-15 | 2024-03-01 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-10-14 | 2021-12-29 | 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 | 2021-10-14 | 2021-12-29 | N |
| Provide activities to meet all resident's needs. | Health | 2021-10-14 | 2021-12-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-14 | 2021-12-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-14 | 2021-12-29 | 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 | 2021-10-14 | 2021-12-29 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-10-14 | 2021-12-29 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-10-14 | 2021-12-29 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-10-12 | 2021-12-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-10-12 | 2021-12-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-10-12 | 2021-12-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-10-12 | 2021-12-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-10-12 | 2021-12-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-10-12 | 2021-12-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-06-20 | 2019-08-06 | 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 | 2019-06-20 | 2019-08-06 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-06-20 | 2019-08-06 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-06-20 | 2019-08-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-20 | 2019-08-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-06-20 | 2019-08-06 | 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 | 2019-06-20 | 2019-08-06 | 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 | 2019-06-20 | 2019-08-06 | 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 | 2019-06-19 | 2019-08-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-19 | 2019-08-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-19 | 2019-08-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-06-19 | 2019-08-06 | N |
