A list of the most recent deficiencies for Legacy Marion. 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 organize and participate in resident/family groups in the facility. | Health | 2023-07-18 | 2023-07-21 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-07-18 | 2023-07-21 | Y |
| 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 | 2023-07-18 | 2023-07-21 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-02-26 | 2023-03-10 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-02-10 | 2023-03-10 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-10 | 2023-03-10 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-02-10 | 2023-03-10 | Y |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2023-02-10 | 2023-03-10 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-09-22 | 2022-11-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-22 | 2022-11-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-22 | 2022-11-11 | 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 | 2022-09-22 | 2022-11-11 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2022-09-22 | 2022-11-11 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-22 | 2022-11-11 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-09-20 | 2022-11-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-20 | 2022-11-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-09-20 | 2022-11-11 | N |
| Ensure electrical receptacles or cover plates have distinctive color or marking. | Fire Safety | 2022-09-20 | 2022-11-11 | 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 | 2019-09-26 | 2019-11-20 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-09-26 | 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 | 2019-09-26 | 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 | 2019-09-26 | 2019-11-20 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-09-25 | 2019-11-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-09-25 | 2019-11-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-09-25 | 2019-11-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-09-25 | 2019-11-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-25 | 2019-11-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-09-25 | 2019-11-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-25 | 2019-11-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-25 | 2019-11-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-25 | 2019-11-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-25 | 2019-11-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-07-19 | 2018-08-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-07-19 | 2018-08-28 | 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 | 2018-07-19 | 2018-08-28 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-07-19 | 2018-08-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-07-19 | 2018-08-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-07-19 | 2018-08-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-07-19 | 2018-08-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-07-19 | 2018-08-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-07-19 | 2018-08-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-07-19 | 2018-08-28 | 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 | 2018-07-19 | 2018-08-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-07-19 | 2018-08-28 | 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 | 2018-07-19 | 2018-08-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-19 | 2018-08-28 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2018-07-19 | 2018-08-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-19 | 2018-08-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-07-18 | 2018-08-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-07-18 | 2018-08-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-07-18 | 2018-08-28 | N |
