A list of the most recent deficiencies for Legacies 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-20 | 2024-01-16 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-12-20 | 2024-01-16 | Y |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-12-20 | 2024-01-16 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-02 | 2022-12-01 | 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 | 2022-11-02 | 2022-12-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-02 | 2022-12-01 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-11-02 | 2022-12-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-02 | 2022-12-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-11-03 | 2022-12-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-30 | 2021-11-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-09-30 | 2021-11-15 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-09-21 | 2021-10-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-09-21 | 2021-10-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-21 | 2021-10-20 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2019-07-23 | 2019-08-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-23 | 2019-08-22 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-07-23 | 2019-08-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-07-23 | 2019-08-22 | 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 | 2019-07-23 | 2019-08-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-23 | 2019-08-22 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-07-23 | 2019-08-22 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-07-23 | 2019-08-22 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-07-23 | 2019-08-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-07-22 | 2019-08-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-07-22 | 2019-08-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-22 | 2019-08-22 | N |
