A list of the most recent deficiencies for Legacy Centerville. 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 | 2023-12-13 | 2023-12-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-13 | 2023-12-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-13 | 2023-12-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-27 | 2023-02-14 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-06-16 | 2022-08-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-16 | 2022-08-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-16 | 2022-08-11 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-06-13 | 2022-08-11 | 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 | 2022-06-13 | 2022-08-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-06-13 | 2022-08-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-06-13 | 2022-08-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-13 | 2022-08-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-13 | 2022-08-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-06-13 | 2022-08-11 | 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 | 2021-09-01 | 2021-09-30 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2021-09-01 | 2021-09-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-16 | 2021-04-06 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-06-20 | 2019-07-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-06-20 | 2019-07-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-20 | 2019-07-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-06-20 | 2019-07-08 | 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 | 2019-06-20 | 2019-07-08 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-06-17 | 2019-07-08 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2019-06-17 | 2019-07-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-17 | 2019-07-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-17 | 2019-07-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-06-17 | 2019-07-08 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-06-17 | 2019-07-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-05-23 | 2018-07-03 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-05-23 | 2018-07-03 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-05-23 | 2018-07-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-05-23 | 2018-07-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-23 | 2018-07-03 | 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 | 2018-05-23 | 2018-07-03 | 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 | 2018-05-23 | 2018-07-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-05-23 | 2018-07-03 | 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 | 2018-05-23 | 2018-07-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-05-23 | 2018-07-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-05-23 | 2018-07-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-23 | 2018-07-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-23 | 2018-07-03 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2018-05-23 | 2018-07-03 | N |
| Install proper backup exit lighting. | Fire Safety | 2018-05-23 | 2018-07-03 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-05-23 | 2018-07-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-05-23 | 2018-07-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-05-23 | 2018-07-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-05-23 | 2018-07-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-05-23 | 2018-07-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-05-23 | 2018-07-03 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-05-23 | 2018-07-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-05-23 | 2018-07-03 | N |
