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Deficiency Records for Legacy Dublin
A list of the most recent deficiencies for Legacy Dublin. 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 Dublin. 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? |
|---|---|---|---|---|
| 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 | 2024-08-22 | 2024-08-23 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-07-15 | 2024-07-16 | 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 | 2024-07-15 | 2024-07-16 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-15 | 2024-07-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-07-15 | 2024-07-16 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-07-15 | 2024-07-16 | 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 | 2024-06-12 | 2024-07-16 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-06-12 | 2024-07-16 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-06-12 | 2024-07-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-06-12 | 2024-07-16 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-08 | 2024-02-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-08 | 2024-02-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-02-08 | 2024-02-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-08 | 2024-02-26 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-02-08 | 2024-02-26 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-02-08 | 2024-02-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-08 | 2024-02-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-08 | 2024-01-08 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-05-08 | 2023-05-09 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-04-18 | 2023-04-28 | 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 | 2022-03-31 | 2022-04-18 | 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 | 2021-11-18 | 2021-12-20 | 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 | 2021-11-18 | 2021-12-20 | 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 | 2021-11-18 | 2021-12-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-11-16 | 2021-12-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-11-16 | 2021-12-20 | 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 | 2019-05-28 | 2019-07-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-05-28 | 2019-07-10 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-05-28 | 2019-06-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-05-28 | 2019-06-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-28 | 2019-06-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-05-28 | 2019-06-26 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2019-05-28 | 2019-06-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-28 | 2019-06-26 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-05-28 | 2019-06-26 | 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 | 2019-05-15 | 2019-06-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-15 | 2019-06-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-15 | 2019-06-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-03-29 | 2018-05-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-03-29 | 2018-05-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-03-29 | 2018-05-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-03-29 | 2018-05-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-03-29 | 2018-05-18 | N |
| Have a combustible roofing system that meets safety standards. | Fire Safety | 2018-03-28 | 2018-05-18 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-03-28 | 2018-05-18 | 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 | 2018-03-28 | 2018-05-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-03-28 | 2018-05-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-03-28 | 2018-05-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-03-28 | 2018-05-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-03-28 | 2018-05-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-03-28 | 2018-05-18 | N |
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