Deficiency Records for Legacy Hillsboro
Updated as of July 01, 2021
This is not the most recent data for Legacy Hillsboro. For the most recent information, click here.
A list of the most recent deficiencies for Legacy Hillsboro. 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? |
|---|---|---|---|---|
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2019-09-26 | 2019-11-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-26 | 2019-11-01 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-09-26 | 2019-11-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-26 | 2019-11-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-26 | 2019-11-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-26 | 2019-11-01 | 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 | 2019-09-26 | 2019-11-01 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-08-09 | 2018-09-30 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-08-09 | 2018-09-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-08-09 | 2018-09-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-09 | 2018-09-30 | N |
| Install proper backup exit lighting. | Fire Safety | 2017-06-21 | 2017-07-24 | 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 | 2017-06-21 | 2017-07-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-06-21 | 2017-07-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-06-21 | 2017-07-24 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-06-22 | 2017-07-24 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-06-22 | 2017-07-24 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-06-22 | 2017-07-24 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-06-22 | 2017-07-24 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-06-22 | 2017-07-24 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-06-22 | 2017-07-24 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-06-22 | 2017-07-24 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-06-22 | 2017-07-24 | N |
