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Deficiency Records for Legacy Marietta
A list of the most recent deficiencies for Legacy Marietta. 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 Marietta. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-06-10 | 2024-07-11 | Y |
| Provide appropriate foot care. | Health | 2024-06-10 | 2024-07-11 | Y |
| Post nurse staffing information every day. | Health | 2024-06-10 | 2024-07-11 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-06-10 | 2024-07-11 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-04-18 | 2024-07-11 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-04-18 | 2024-07-11 | Y |
| 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 | 2024-04-18 | 2024-07-11 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-04-18 | 2024-07-11 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2024-04-18 | 2024-07-11 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-04-18 | 2024-07-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-04-18 | 2024-07-11 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-04-18 | 2024-07-11 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2024-04-18 | 2024-07-11 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-04-18 | 2024-07-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-18 | 2024-07-11 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-04-18 | 2024-07-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-18 | 2024-07-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-18 | 2024-07-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-04-18 | 2024-07-11 | 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 | 2024-04-18 | 2024-07-11 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-04-18 | 2024-07-11 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-04-18 | 2024-07-11 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-04-18 | 2024-07-11 | 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 | 2024-04-18 | 2024-07-11 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-04-18 | 2024-07-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-04-18 | 2024-07-11 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-04-18 | 2024-07-11 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-04-18 | 2024-07-11 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-04-18 | 2024-07-11 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-04-18 | 2024-07-11 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2024-04-18 | 2024-07-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-04-18 | 2024-07-11 | Y |
| Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel. | Health | 2024-04-18 | 2024-07-11 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-04-18 | 2024-07-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-04-18 | 2024-07-11 | Y |
| Implement a program that monitors antibiotic use. | Health | 2024-04-18 | 2024-07-11 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-04-18 | 2024-07-11 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-04-18 | 2024-07-11 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-03 | 2023-02-22 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-02-03 | 2023-02-22 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-02-03 | 2023-02-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-03 | 2023-02-22 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-02-03 | 2023-02-22 | N |
| 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 | 2023-02-03 | 2023-02-22 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-02-03 | 2023-02-22 | 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 | 2023-02-03 | 2023-02-22 | 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 | 2023-02-03 | 2023-02-22 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-02-03 | 2023-02-22 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-01-30 | 2023-02-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-01-30 | 2023-02-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-30 | 2023-02-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-30 | 2023-02-22 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-01-30 | 2023-02-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-30 | 2022-12-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-30 | 2022-12-21 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-30 | 2022-12-21 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-04-28 | 2022-05-18 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-03-31 | 2022-05-18 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-01-12 | 2022-01-28 | 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 | 2022-01-12 | 2022-01-28 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-01-12 | 2022-01-28 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-01-12 | 2022-01-28 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-10-08 | 2021-11-05 | 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 | 2021-04-30 | 2021-07-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-30 | 2021-07-07 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-04-30 | 2021-07-07 | 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 | 2021-04-30 | 2021-07-07 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-30 | 2021-07-07 | 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 | 2021-04-30 | 2021-07-07 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-04-30 | 2021-07-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-30 | 2021-07-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-30 | 2021-07-07 | 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 | 2021-04-30 | 2021-07-07 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-04-30 | 2021-07-07 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-04-30 | 2021-07-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-30 | 2021-07-07 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-04-30 | 2021-07-07 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-04-28 | 2021-07-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-04-28 | 2021-07-06 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-01-31 | 2019-05-07 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-01-31 | 2019-05-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-31 | 2019-05-07 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-01-31 | 2019-05-07 | N |
| 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 | 2019-01-31 | 2019-05-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-01-31 | 2019-05-07 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-01-31 | 2019-05-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-01-31 | 2019-05-07 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-01-31 | 2019-05-07 | 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 | 2019-01-31 | 2019-05-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-01-31 | 2019-05-07 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-01-31 | 2019-05-07 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-01-31 | 2019-04-03 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-01-31 | 2019-04-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-31 | 2019-04-03 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2019-01-31 | 2019-04-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-01-31 | 2019-04-03 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-01-31 | 2019-04-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-01-31 | 2019-04-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-01-31 | 2019-04-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-01-31 | 2019-04-03 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-01-31 | 2019-04-03 | 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 | 2019-01-31 | 2019-04-03 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-01-31 | 2019-04-03 | N |
| Provide or obtain dental services for each resident. | Health | 2019-01-31 | 2019-04-03 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-01-31 | 2019-04-03 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-01-31 | 2019-04-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-31 | 2019-04-03 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-01-31 | 2019-04-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-01-29 | 2019-04-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-01-29 | 2019-04-03 | N |
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