Deficiency Records for Legend Oaks Healthcare and Rehabilitation - West S
Updated as of March 01, 2024
A list of the most recent deficiencies for Legend Oaks Healthcare and Rehabilitation - West S. 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? |
|---|---|---|---|---|
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-09-15 | 2023-10-12 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-09-15 | 2023-10-12 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-09-15 | 2023-10-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-15 | 2023-10-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-15 | 2023-10-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-15 | 2022-08-11 | 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 | 2022-07-15 | 2022-07-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-21 | 2022-05-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-09 | 2022-03-03 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-09-17 | 2021-10-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-17 | 2021-10-13 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-04-14 | 2021-05-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-14 | 2021-05-14 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-04-14 | 2021-05-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-04-14 | 2021-05-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-16 | 2021-05-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-04-16 | 2021-05-05 | 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 | 2021-04-16 | 2021-05-05 | N |
