A list of the most recent deficiencies for Legacy Health and Rehab. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-19 | 2023-10-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-29 | 2021-12-11 | 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 | 2021-10-27 | 2021-12-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-10-27 | 2021-12-03 | 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 | 2021-10-27 | 2021-12-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-27 | 2021-12-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-10-25 | 2021-12-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-10-25 | 2021-12-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-04-01 | 2019-09-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-01 | 2019-07-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-04-01 | 2019-07-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-03 | 2019-05-17 | 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 | 2019-04-03 | 2019-05-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-03 | 2019-05-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-03 | 2019-05-17 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-04-03 | 2019-05-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-03 | 2019-05-17 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-04-01 | 2019-05-17 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-04-01 | 2019-05-17 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-04-01 | 2019-05-17 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-04-01 | 2019-05-17 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-04-01 | 2019-05-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-04-01 | 2019-05-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-04-01 | 2019-05-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-04-01 | 2019-05-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-01 | 2019-05-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-01 | 2019-05-17 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-04-04 | 2018-05-07 | N |
| Respond appropriately to all alleged violations. | Health | 2018-04-04 | 2018-05-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-04-03 | 2018-05-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-04-03 | 2018-05-07 | N |
