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Deficiency Records for Legacy Kettering
A list of the most recent deficiencies for Legacy Kettering. 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 Kettering. 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 pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-09-23 | 2024-09-24 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2024-06-26 | 2024-07-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-06-26 | 2024-07-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-06-26 | 2024-07-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-06-26 | 2024-07-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-06-26 | 2024-07-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-06-26 | 2024-07-03 | N |
| Post nurse staffing information every day. | Health | 2024-06-14 | 2024-07-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-06-14 | 2024-07-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-02-05 | 2024-02-12 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-02-05 | 2024-02-12 | Y |
| 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 | 2024-02-05 | 2024-02-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-08 | 2023-11-22 | Y |
| 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 | 2023-10-07 | 2023-11-22 | Y |
| 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 | 2023-05-25 | 2023-06-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-15 | 2022-10-07 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-09-01 | 2022-10-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-11 | 2022-08-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-02 | 2022-03-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-20 | 2022-03-18 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2021-11-08 | 2021-12-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-08 | 2021-12-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-11-08 | 2021-12-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-08 | 2021-12-17 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-11-08 | 2021-12-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-08 | 2021-12-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-08 | 2021-12-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-08 | 2021-12-17 | Y |
| 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 | 2021-11-08 | 2021-12-17 | Y |
| Establish emergency prep training and testing. | Fire Safety | 2021-11-02 | 2021-12-17 | 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 | 2021-11-02 | 2021-12-17 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-11-02 | 2021-12-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-11-02 | 2021-12-17 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-11-02 | 2021-12-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-11-02 | 2021-12-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-02 | 2021-12-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-11-02 | 2021-12-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-11-02 | 2021-12-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-11-02 | 2021-12-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-11-02 | 2021-12-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-02 | 2021-12-17 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-11-02 | 2021-12-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-02 | 2021-12-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-11-02 | 2021-12-17 | N |
| Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled. | Fire Safety | 2021-11-02 | 2021-12-17 | N |
| 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 | 2019-02-28 | 2019-04-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-02-28 | 2019-04-01 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-02-28 | 2019-04-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-28 | 2019-04-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-02-28 | 2019-04-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-02-28 | 2019-04-01 | 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 | 2019-02-28 | 2019-04-01 | N |
| Provide or obtain dental services for each resident. | Health | 2019-02-28 | 2019-04-01 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2019-02-28 | 2019-04-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-02-28 | 2019-04-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-02-28 | 2019-04-01 | N |
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