A list of the most recent deficiencies for Legacy at Jacksonville. 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? |
|---|---|---|---|---|
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-01 | 2023-01-01 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-12-01 | 2023-01-01 | 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 | 2022-12-01 | 2023-01-01 | 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 | 2022-12-01 | 2023-01-01 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2022-12-01 | 2023-01-01 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2022-12-01 | 2023-01-01 | 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 | 2022-12-01 | 2023-01-01 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-15 | 2021-10-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-15 | 2021-10-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-06-23 | 2021-08-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-23 | 2021-08-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-06-23 | 2021-08-30 | Y |
| Meet other general requirements. | Fire Safety | 2019-11-19 | 2020-01-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-11-19 | 2020-01-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-19 | 2020-01-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-11-19 | 2020-01-18 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-11-21 | 2019-12-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-11-21 | 2019-12-21 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2019-11-21 | 2019-12-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-21 | 2019-12-21 | N |
