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? |
|---|---|---|---|---|
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-08-11 | 2023-09-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-11 | 2023-09-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-10 | 2022-06-30 | 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 | 2022-06-10 | 2022-06-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-10 | 2022-06-30 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-06-10 | 2022-06-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-11 | 2022-03-16 | Y |
| 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 | 2019-10-09 | 2019-11-05 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-10-09 | 2019-11-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-09 | 2019-11-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-09 | 2019-11-05 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-10-09 | 2019-10-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-10-09 | 2019-10-30 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2019-10-09 | 2019-10-30 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2019-10-09 | 2019-10-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-09 | 2019-10-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-09 | 2019-10-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-10-09 | 2019-10-22 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-10-09 | 2019-10-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-09 | 2019-10-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-09 | 2019-10-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-10-03 | 2018-10-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-10-03 | 2018-10-26 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2018-10-03 | 2018-10-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-03 | 2018-10-26 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-10-02 | 2018-10-26 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2018-10-02 | 2018-10-17 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2018-10-02 | 2018-10-16 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-10-02 | 2018-10-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-10-02 | 2018-10-05 | N |
