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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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