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? |
|---|---|---|---|---|
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-01-23 | 2024-03-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-23 | 2024-03-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-23 | 2024-03-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-01-23 | 2024-03-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-01-23 | 2024-03-01 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-12-20 | 2024-01-16 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-12-20 | 2024-01-16 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-20 | 2024-01-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-20 | 2024-01-16 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-12-20 | 2024-01-16 | N |
| 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 |
