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Deficiency Records for Legacy Beavercreek
A list of the most recent deficiencies for Legacy Beavercreek. 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 Beavercreek. 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 a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-08-14 | 2024-08-21 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-05-01 | 2024-05-13 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-02-05 | 2024-02-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-30 | 2023-06-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-05 | 2023-06-15 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-08-11 | 2022-09-17 | 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 | 2022-08-11 | 2022-09-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-08-11 | 2022-09-17 | 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 | 2022-08-08 | 2022-09-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-08 | 2022-09-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-08 | 2022-09-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-08-08 | 2022-09-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-08-08 | 2022-09-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-08 | 2022-09-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-30 | 2022-03-31 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-03-10 | 2022-03-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-17 | 2022-03-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-17 | 2022-03-31 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-01-13 | 2022-03-31 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-07-25 | 2019-10-08 | 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 | 2019-07-25 | 2019-10-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-07-25 | 2019-10-08 | N |
| 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 | 2019-07-25 | 2019-10-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-25 | 2019-10-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-25 | 2019-10-08 | N |
| Provide activities to meet all resident's needs. | Health | 2019-07-25 | 2019-10-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-25 | 2019-10-08 | 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 | 2019-07-25 | 2019-10-08 | 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 | 2019-07-24 | 2019-10-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-24 | 2019-10-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-07-24 | 2019-10-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-24 | 2019-10-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-24 | 2019-10-08 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-06-14 | 2018-07-27 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-06-14 | 2018-07-27 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-06-14 | 2018-07-27 | 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 | 2018-06-14 | 2018-07-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-06-14 | 2018-07-27 | N |
| 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 | 2018-06-14 | 2018-07-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-06-14 | 2018-07-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-06-14 | 2018-07-27 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-06-14 | 2018-07-27 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-06-14 | 2018-07-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-06-14 | 2018-07-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-06-14 | 2018-07-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-06-12 | 2018-07-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-06-12 | 2018-07-27 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-06-12 | 2018-07-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-06-12 | 2018-07-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-06-12 | 2018-07-27 | N |
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