A list of the most recent deficiencies for Legacy Mentor. 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? |
|---|---|---|---|---|
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-23 | 2023-06-27 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-06-01 | 2023-06-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-01 | 2023-06-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-01 | 2023-06-27 | 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 | 2023-06-01 | 2023-06-27 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-19 | 2022-10-25 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-09-19 | 2022-10-25 | 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 | 2022-09-19 | 2022-10-25 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-19 | 2022-10-25 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-09-19 | 2022-10-25 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-09-19 | 2022-10-25 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-09-19 | 2022-10-25 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-09-19 | 2022-10-25 | 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 | 2022-09-19 | 2022-10-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-19 | 2022-10-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-19 | 2022-10-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-09-13 | 2022-10-25 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-09-13 | 2022-10-25 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-09-13 | 2022-10-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-09-13 | 2022-10-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-13 | 2022-10-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-09-13 | 2022-10-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-13 | 2022-10-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-09-13 | 2022-10-25 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-09-13 | 2022-10-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-13 | 2022-10-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-13 | 2022-10-25 | 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 | 2022-02-24 | 2022-03-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-10 | 2021-09-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-29 | 2021-08-17 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-03-11 | 2021-03-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-13 | 2019-12-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-13 | 2019-12-10 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-09-10 | 2019-12-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-09-13 | 2019-11-20 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-09-13 | 2019-11-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-09-13 | 2019-11-20 | 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 | 2019-09-13 | 2019-11-20 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-09-13 | 2019-11-20 | 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 | 2019-09-13 | 2019-11-20 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-09-13 | 2019-11-20 | 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 | 2019-09-13 | 2019-11-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-09-13 | 2019-11-20 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-09-13 | 2019-11-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-13 | 2019-11-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-13 | 2019-11-20 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-09-10 | 2019-11-19 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-09-10 | 2019-11-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-10 | 2019-11-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-10 | 2019-11-19 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2019-09-10 | 2019-11-19 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-09-13 | 2019-10-28 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-09-13 | 2019-10-28 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-09-10 | 2019-10-28 | N |
| Establish methods for sharing information. | Fire Safety | 2019-09-10 | 2019-10-28 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-09-10 | 2019-10-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-16 | 2018-09-12 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2018-08-16 | 2018-09-12 | 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 | 2018-08-16 | 2018-09-12 | 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 | 2018-08-16 | 2018-09-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-16 | 2018-09-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-16 | 2018-09-12 | N |
