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Deficiency Records for The Legacy Living and Rehabilitation Center

A list of the most recent deficiencies for The Legacy Living and Rehabilitation Center. 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 The Legacy Living and Rehabilitation Center. 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?
Meet requirements for the installation and maintenance of electrical systems. Fire Safety 2024-05-22 2024-08-07 N
Ensure residents have reasonable access to and privacy in their use of communication methods. Health 2024-05-23 2024-06-17 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 2024-05-23 2024-06-17 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-05-23 2024-06-17 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-05-23 2024-06-17 Y
Respond appropriately to all alleged violations. Health 2024-05-23 2024-06-17 Y
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2024-05-23 2024-06-17 Y
Ensure each resident receives an accurate assessment. Health 2024-05-23 2024-06-17 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-05-23 2024-06-17 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2024-05-23 2024-06-17 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-05-23 2024-06-17 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 2024-05-23 2024-06-17 Y
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Health 2024-05-23 2024-06-17 Y
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2024-05-23 2024-06-17 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-05-23 2024-06-17 Y
Provide and implement an infection prevention and control program. Health 2024-05-23 2024-06-17 Y
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-05-22 2024-06-17 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2024-05-22 2024-06-17 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-02-27 2024-02-15 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 2023-09-22 2023-11-06 Y
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Health 2023-09-22 2023-11-06 Y
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Health 2023-09-22 2023-11-06 Y
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2023-09-22 2023-11-06 Y
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Health 2023-09-22 2023-11-06 Y
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2023-03-09 2023-04-23 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-03-09 2023-04-23 N
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Health 2023-03-09 2023-04-23 N
Meet requirements for the use of electrical equipment. Fire Safety 2023-03-08 2023-03-29 N
Install an approved automatic sprinkler system. Fire Safety 2023-03-08 2023-03-22 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 2023-03-08 2023-03-17 N
Provide properly protected cooking facilities. Fire Safety 2023-03-08 2023-03-17 N
Have exits that are accessible at all times. Fire Safety 2023-03-08 2023-03-16 N
Install a fire alarm system that can be heard throughout the facility. Fire Safety 2023-03-08 2023-03-15 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-03-08 2023-03-15 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2023-03-08 2023-03-15 N
Provide emergency officials' contact information. Fire Safety 2023-03-08 2023-03-09 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-03-08 2023-03-09 N
Have stairways and smokeproof enclosures used as exits that meet safety requirements. Fire Safety 2023-03-08 2023-03-08 N
Have restrictions on the use of portable space heaters. Fire Safety 2023-03-08 2023-03-08 N
Meet other general requirements. Fire Safety 2023-03-08 2023-03-08 N
Provide emergency officials' contact information. Fire Safety 2021-12-03 2022-01-19 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 2021-12-03 2022-01-19 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 2021-12-03 2022-01-19 N
Have stairways and smokeproof enclosures used as exits that meet safety requirements. Fire Safety 2021-12-03 2022-01-19 N
Install an approved automatic sprinkler system. Fire Safety 2021-12-03 2022-01-19 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2021-12-03 2022-01-19 N
Have restrictions on the use of highly flammable decorations. Fire Safety 2021-12-03 2022-01-19 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2021-12-02 2022-01-16 N
Provide activities to meet all resident's needs. Health 2021-12-02 2022-01-16 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2021-12-02 2022-01-16 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-12-02 2022-01-16 N
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Health 2021-12-02 2022-01-16 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 2021-12-02 2022-01-16 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 2023-03-08 Not Fixed N

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