Deficiency Records for Legacies Nursing and Rehabilitation
Updated as of July 01, 2021
This is not the most recent data for Legacies Nursing and Rehabilitation. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| 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 |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2018-10-15 | 2018-11-15 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-10-15 | 2018-11-15 | Y |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-07-10 | 2018-09-30 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2018-07-11 | 2018-08-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-07-11 | 2018-08-11 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2018-07-11 | 2018-08-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-07-11 | 2018-08-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-07-11 | 2018-08-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-07-11 | 2018-08-11 | 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 | 2018-07-11 | 2018-08-11 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-07-11 | 2018-08-11 | 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 | 2018-07-11 | 2018-08-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-07-11 | 2018-08-11 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2018-07-11 | 2018-08-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-11-08 | 2017-12-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-11-08 | 2017-12-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-11-08 | 2017-12-07 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-11-08 | 2017-12-07 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-11-08 | 2017-12-07 | N |
