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Deficiency Records for Legacy On 10th Avenue

A list of the most recent deficiencies for Legacy On 10th Avenue. 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 On 10th Avenue. 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?
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2024-06-18 2024-07-19 Y
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. Health 2024-06-18 2024-07-19 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2024-04-23 2024-05-31 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 2023-10-25 2023-12-06 Y
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Health 2023-10-25 2023-12-06 Y
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2023-10-02 2023-10-27 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-07-11 2023-08-04 Y
Respond appropriately to all alleged violations. Health 2023-07-11 2023-08-04 Y
Provide care or services that was trauma informed and/or culturally competent. Health 2023-07-11 2023-08-04 Y
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2023-04-18 2023-06-30 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 2023-04-18 2023-06-30 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-04-18 2023-06-30 Y
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2023-05-11 2023-06-15 N
Establish procedures for tracking staff and patients during an emergency. Fire Safety 2023-05-11 2023-06-15 N
Establish roles under a Waiver declared by secretary. Fire Safety 2023-05-11 2023-06-15 N
Provide emergency officials' contact information. Fire Safety 2023-05-11 2023-06-15 N
Provide primary/alternate means for communication. Fire Safety 2023-05-11 2023-06-15 N
Establish emergency prep training and testing. Fire Safety 2023-05-11 2023-06-15 N
Establish staff and initial training requirements. Fire Safety 2023-05-11 2023-06-15 N
Conduct testing and exercise requirements. Fire Safety 2023-05-11 2023-06-15 N
Use approved construction type or materials. Fire Safety 2023-05-11 2023-06-15 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2023-05-11 2023-06-15 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2023-05-11 2023-06-15 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 2023-05-11 2023-06-15 N
Provide properly protected cooking facilities. Fire Safety 2023-05-11 2023-06-15 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-05-11 2023-06-15 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-05-11 2023-06-15 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2023-05-11 2023-06-15 N
Install corridor and hallway doors that block smoke. Fire Safety 2023-05-11 2023-06-15 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2023-05-11 2023-06-15 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2023-05-11 2023-06-15 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-05-11 2023-06-15 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2023-05-11 2023-06-15 N
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. Fire Safety 2023-05-11 2023-06-15 N
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2023-04-18 2023-05-22 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2023-04-18 2023-05-22 N
Provide enough food/fluids to maintain a resident's health. Health 2023-04-18 2023-05-22 N
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Health 2023-04-18 2023-05-22 N
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Health 2023-04-18 2023-05-22 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 2023-04-18 2023-05-22 N
Provide and implement an infection prevention and control program. Health 2023-04-18 2023-05-22 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-04-18 2023-05-22 Y
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Health 2023-04-18 2023-05-22 Y
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2023-04-18 2023-05-22 Y
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Health 2023-04-18 2023-05-22 Y
Provide and implement an infection prevention and control program. Health 2022-11-01 2022-12-07 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-08-22 2022-09-09 Y
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2021-11-17 2021-12-20 N
Conduct risk assessment and an All-Hazards approach. Fire Safety 2021-11-17 2021-12-20 N
Include a process for Emergency Preparedness collaboration. Fire Safety 2021-11-17 2021-12-20 N
Establish policies and procedures for volunteers. Fire Safety 2021-11-17 2021-12-20 N
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Fire Safety 2021-11-17 2021-12-20 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2021-11-17 2021-12-20 N
Have properly located and lighted "Exit" signs. Fire Safety 2021-11-17 2021-12-20 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 2021-11-17 2021-12-20 N
Provide properly protected cooking facilities. Fire Safety 2021-11-17 2021-12-20 N
Have properly installed hallway dispensers for alcohol-based hand rub. Fire Safety 2021-11-17 2021-12-20 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2021-11-17 2021-12-20 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2021-11-17 2021-12-20 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2021-11-17 2021-12-20 N
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Fire Safety 2021-11-17 2021-12-20 N
Install corridor and hallway doors that block smoke. Fire Safety 2021-11-17 2021-12-20 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2021-11-17 2021-12-20 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2021-11-17 2021-12-20 N
Have simulated fire drills held at unexpected times. Fire Safety 2021-11-17 2021-12-20 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2021-11-17 2021-12-20 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2021-11-17 2021-12-20 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2021-11-17 2021-12-20 N
Ensure proper usage of power strips and extension cords. Fire Safety 2021-11-17 2021-12-20 N
Have proper medical gas storage and administration areas. Fire Safety 2021-11-17 2021-12-20 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2021-10-25 2021-11-25 N
Implement a program that monitors antibiotic use. Health 2021-10-25 2021-11-25 N
Put firmly secured handrails on each side of hallways. Health 2021-10-25 2021-11-25 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 2021-10-25 2021-11-25 Y
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Health 2019-11-21 2019-12-21 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2019-11-21 2019-12-21 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2019-11-21 2019-12-21 N
Create arrangements with other facilities to receive patients. Fire Safety 2019-10-15 2019-11-15 N
Establish staff and initial training requirements. Fire Safety 2019-10-15 2019-11-15 N
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Fire Safety 2019-10-15 2019-11-15 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2019-10-15 2019-11-15 N
Install corridor and hallway doors that block smoke. Fire Safety 2019-10-15 2019-11-15 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2019-10-15 2019-11-15 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2019-10-15 2019-11-15 N
Ensure proper usage of power strips and extension cords. Fire Safety 2019-10-15 2019-11-15 N

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