A list of the most recent deficiencies for Legacy Rehabilitation and Living. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-06 | 2023-10-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-14 | 2023-05-26 | N |
| 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 | 2023-04-14 | 2023-05-26 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-04-14 | 2023-05-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-14 | 2023-05-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-14 | 2023-05-26 | 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 | 2023-04-14 | 2023-05-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-14 | 2023-05-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-14 | 2023-05-26 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-02-24 | 2023-03-21 | 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 | 2022-07-14 | 2022-07-15 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-07-14 | 2022-07-15 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-06-02 | 2022-06-22 | Y |
| 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 | 2022-03-29 | 2022-04-17 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-03-09 | 2022-04-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-09 | 2022-04-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-09 | 2022-04-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-09 | 2022-04-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-03-09 | 2022-04-01 | 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 | 2022-03-09 | 2022-04-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-09 | 2022-04-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-08 | 2022-03-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-08 | 2021-11-15 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-10-08 | 2021-10-18 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-09-22 | 2021-10-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-25 | 2021-08-26 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-08-11 | 2021-08-12 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-08-11 | 2021-08-12 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-06-15 | 2021-07-01 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-06-15 | 2021-07-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-13 | 2021-05-15 | 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 | 2021-04-13 | 2021-05-15 | 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 | 2021-04-13 | 2021-05-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-13 | 2021-05-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-13 | 2021-05-15 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-04-13 | 2021-05-15 | N |
