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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?
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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