Deficiency Records for Legend Oaks Healthcare and Rehabilitation - New Br
Updated as of March 01, 2024
A list of the most recent deficiencies for Legend Oaks Healthcare and Rehabilitation - New Br. 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? |
|---|---|---|---|---|
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-23 | 2024-03-04 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-01-27 | 2024-02-29 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-01-27 | 2024-02-29 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-27 | 2024-02-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-01-27 | 2024-02-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-20 | 2024-02-11 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-27 | 2024-01-29 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-11-18 | 2022-12-31 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2022-11-18 | 2022-12-31 | Y |
| 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 | 2022-11-18 | 2022-12-15 | Y |
| 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 | 2022-11-18 | 2022-12-12 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-17 | 2022-12-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-11-17 | 2022-12-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-18 | 2022-11-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-01 | 2022-09-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-01 | 2022-09-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-24 | 2021-10-16 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-09-24 | 2021-10-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-09-24 | 2021-10-16 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-09-24 | 2021-10-16 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-09-24 | 2021-10-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-24 | 2021-10-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-24 | 2021-10-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-09-24 | 2021-10-16 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-08-10 | 2021-08-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-10 | 2021-08-11 | Y |
