A list of the most recent deficiencies for Legacy Nursing and Rehabilitation. 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-07 | 2024-01-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-27 | 2023-03-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-27 | 2023-03-03 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-01-27 | 2023-03-03 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-01-27 | 2023-03-03 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-01-27 | 2023-03-03 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-01-27 | 2023-03-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-27 | 2023-03-03 | N |
| Dispose of garbage and refuse properly. | Health | 2023-01-27 | 2023-03-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-27 | 2023-03-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-06 | 2021-12-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-06 | 2021-12-31 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-10 | 2021-12-01 | 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 | 2021-11-10 | 2021-12-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-10 | 2021-12-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-10 | 2021-12-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-11-10 | 2021-12-01 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-11-10 | 2021-12-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-05-20 | 2021-05-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-20 | 2021-05-31 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2020-03-12 | 2020-04-15 | 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 | 2020-03-12 | 2020-04-15 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2020-03-11 | 2020-04-15 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2020-03-11 | 2020-04-15 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-03-11 | 2020-04-15 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2020-03-11 | 2020-04-15 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2020-03-11 | 2020-04-15 | N |
| Develop a communication plan. | Fire Safety | 2020-03-11 | 2020-04-15 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2020-03-11 | 2020-04-15 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-03-11 | 2020-04-15 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2020-03-11 | 2020-04-15 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2020-03-11 | 2020-04-15 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2020-03-11 | 2020-04-15 | N |
| Establish emergency prep training and testing. | Fire Safety | 2020-03-11 | 2020-04-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2020-03-11 | 2020-04-15 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-03-12 | 2020-03-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-03-12 | 2020-03-31 | 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 | 2020-03-12 | 2020-03-31 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-03-11 | 2020-03-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-12 | 2020-03-15 | N |
