A list of the most recent deficiencies for Legacy Post Acute Care. 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? |
|---|---|---|---|---|
| List the names and contact information of those in the facility. | Fire Safety | 2022-10-19 | 2022-11-29 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-10-19 | 2022-11-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-10-19 | 2022-11-29 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-10-19 | 2022-11-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-19 | 2022-11-29 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-10-19 | 2022-11-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-19 | 2022-11-29 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-10-19 | 2022-11-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-10-19 | 2022-11-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-19 | 2022-11-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-19 | 2022-11-29 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-10-19 | 2022-11-29 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-10-14 | 2022-11-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-14 | 2022-11-14 | 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 | 2022-10-14 | 2022-11-14 | 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 | 2022-10-14 | 2022-11-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-14 | 2022-11-14 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-09-12 | 2019-10-13 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-09-12 | 2019-10-13 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-09-12 | 2019-10-13 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-12 | 2019-10-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-16 | 2019-09-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-08-16 | 2019-09-16 | 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 | 2019-08-16 | 2019-09-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-16 | 2019-09-16 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-11-20 | 2018-12-13 | N |
| Use approved construction type or materials. | Fire Safety | 2018-11-20 | 2018-12-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-20 | 2018-12-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-11-20 | 2018-12-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-11-20 | 2018-12-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-11-20 | 2018-12-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-09-27 | 2018-10-27 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-09-27 | 2018-10-27 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-09-27 | 2018-10-27 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-09-27 | 2018-10-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-09-27 | 2018-10-27 | 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 | 2018-09-27 | 2018-10-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-27 | 2018-10-27 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-09-27 | 2018-10-27 | N |
