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Deficiency Records for Legacy Miamisburg
A list of the most recent deficiencies for Legacy Miamisburg. 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 Miamisburg. 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? |
|---|---|---|---|---|
| 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 | 2024-09-26 | 2024-10-07 | 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 | 2024-09-26 | 2024-10-07 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-09-04 | 2024-09-17 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2024-06-27 | 2024-06-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-27 | 2024-06-28 | 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 | 2024-06-27 | 2024-06-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-16 | 2024-05-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-16 | 2024-05-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-16 | 2024-05-22 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-05-16 | 2024-05-22 | Y |
| 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 | 2024-05-16 | 2024-05-22 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-04-25 | 2024-05-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-28 | 2024-05-22 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-03-28 | 2024-05-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-03-28 | 2024-05-22 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-18 | 2023-12-22 | Y |
| 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 | 2023-08-31 | 2023-09-22 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-31 | 2023-09-22 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-08-31 | 2023-09-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-04 | 2023-04-17 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-08-25 | 2022-09-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-08-25 | 2022-09-30 | 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 | 2022-08-25 | 2022-09-30 | 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 | 2022-08-25 | 2022-09-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-25 | 2022-09-30 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-08-25 | 2022-09-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-25 | 2022-09-30 | 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 | 2022-08-25 | 2022-09-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-25 | 2022-09-30 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-08-25 | 2022-09-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-25 | 2022-09-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-25 | 2022-09-30 | Y |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-08-25 | 2022-09-30 | 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 | 2022-07-22 | 2022-09-30 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-18 | 2022-09-30 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-08-18 | 2022-09-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-18 | 2022-09-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-08-18 | 2022-09-30 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-07-22 | 2022-08-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-22 | 2022-08-25 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-07-12 | 2019-08-30 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2019-07-12 | 2019-08-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-07-12 | 2019-08-30 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-07-12 | 2019-08-30 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-07-12 | 2019-08-30 | 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 | 2019-07-12 | 2019-08-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-12 | 2019-08-30 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-07-12 | 2019-08-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-07-12 | 2019-08-30 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-07-12 | 2019-08-30 | 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 | 2019-07-12 | 2019-08-30 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2019-07-12 | 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 | 2019-07-12 | 2019-08-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-12 | 2019-08-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-07-10 | 2019-08-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-07-10 | 2019-08-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-10 | 2019-08-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-10 | 2019-08-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-07-10 | 2019-08-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-07-10 | 2019-08-30 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2019-07-10 | 2019-08-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-07-10 | 2019-08-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-05-25 | 2018-06-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-05-25 | 2018-06-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-05-25 | 2018-06-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-05-25 | 2018-06-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-05-25 | 2018-06-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-05-25 | 2018-06-25 | N |
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