Deficiency Records for Legacy West Rehabilitation and Healthcare
Updated as of April 01, 2024
A list of the most recent deficiencies for Legacy West Rehabilitation and Healthcare. 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 | 2024-02-21 | 2024-03-21 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-12-07 | 2023-12-29 | Y |
| Have an alternate power supply for its alarm system. | Fire Safety | 2022-08-25 | 2022-10-03 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2022-08-25 | 2022-10-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-25 | 2022-10-03 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-08-25 | 2022-10-03 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-08-11 | 2022-09-20 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-08-11 | 2022-09-20 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-08-11 | 2022-09-20 | 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 | 2022-08-11 | 2022-09-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-11 | 2022-09-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-08-11 | 2022-09-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-08-11 | 2022-09-20 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-08-11 | 2022-09-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-11 | 2022-09-20 | N |
| Post nurse staffing information every day. | Health | 2021-06-17 | 2021-07-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-17 | 2021-07-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-06-17 | 2021-07-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-17 | 2021-07-17 | N |
| Keep all essential equipment working safely. | Health | 2021-06-17 | 2021-07-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-06-17 | 2021-07-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-17 | 2021-07-17 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-06-17 | 2021-07-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-01-23 | 2019-02-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-01-23 | 2019-02-22 | 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 | 2019-01-23 | 2019-02-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-01-23 | 2019-02-22 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-01-23 | 2019-02-22 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-01-25 | 2019-01-31 | N |
