Deficiency Records for Legends Care Rehabilitation and Nursing Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Legends Care Rehabilitation and Nursing Center. 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 voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-12-09 | 2023-12-21 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-13 | 2023-11-30 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-13 | 2023-11-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-13 | 2023-11-30 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-10-11 | 2023-11-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-03 | 2023-08-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-08 | 2023-02-09 | 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 | 2022-10-21 | 2022-11-23 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-10-21 | 2022-11-23 | 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 | 2022-10-21 | 2022-11-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-10-21 | 2022-11-23 | 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 | 2022-10-21 | 2022-11-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-21 | 2022-11-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-21 | 2022-11-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-21 | 2022-11-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-21 | 2022-11-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-22 | 2022-11-23 | Y |
| 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 | 2022-10-12 | 2022-11-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-12 | 2022-11-23 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-10-12 | 2022-11-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-12 | 2022-11-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-12 | 2022-11-23 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-08-20 | 2021-09-08 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-03-22 | 2021-03-30 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-10-18 | 2019-11-01 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-10-18 | 2019-11-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-18 | 2019-11-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-18 | 2019-11-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-18 | 2019-11-01 | 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 | 2019-10-18 | 2019-11-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-10-18 | 2019-11-01 | 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 | 2019-10-18 | 2019-11-01 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-10-18 | 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 | 2019-10-18 | 2019-11-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-18 | 2019-11-01 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-10-16 | 2019-11-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-10-16 | 2019-11-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-16 | 2019-11-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-16 | 2019-11-01 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2019-10-16 | 2019-11-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-16 | 2019-11-01 | 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 | 2018-09-05 | 2018-09-30 | 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 | 2018-09-05 | 2018-09-30 | N |
| Construct fire resistant interior walls. | Fire Safety | 2018-09-05 | 2018-09-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-09-05 | 2018-09-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-09-05 | 2018-09-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-09-05 | 2018-09-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-09-05 | 2018-09-30 | N |
