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Deficiency Records for Legacy Health and Rehabilitation of Pleasant Grove
A list of the most recent deficiencies for Legacy Health and Rehabilitation of Pleasant Grove. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Legacy Health and Rehabilitation of Pleasant Grove. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-26 | 2022-07-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-26 | 2022-07-01 | Y |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2022-02-16 | 2022-03-22 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-02-16 | 2022-03-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-16 | 2022-03-22 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-02-16 | 2022-03-22 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-02-11 | 2022-03-18 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-02-11 | 2022-03-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-11 | 2022-03-18 | 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 | 2022-02-11 | 2022-03-18 | 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 | 2022-02-11 | 2022-03-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-11 | 2022-03-18 | N |
| Dispose of garbage and refuse properly. | Health | 2022-02-11 | 2022-03-18 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-02-11 | 2022-03-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-01 | 2019-08-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-01 | 2019-08-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-01 | 2019-08-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-01 | 2019-08-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-01 | 2019-08-30 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-06-19 | 2019-07-23 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2019-06-19 | 2019-07-23 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-07-03 | 2018-08-06 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-07-03 | 2018-08-06 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-07-03 | 2018-08-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-07-03 | 2018-08-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-07-03 | 2018-08-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-07-03 | 2018-08-06 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2018-06-27 | 2018-07-31 | N |
| Post nurse staffing information every day. | Health | 2018-06-27 | 2018-07-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-06-27 | 2018-07-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-06-27 | 2018-07-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-06-27 | 2018-07-31 | N |
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