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Deficiency Records for Legacy Nursing and Rehabilitation
A list of the most recent deficiencies for Legacy Nursing and Rehabilitation. 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 Nursing and Rehabilitation. 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? |
|---|---|---|---|---|
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-08-09 | 2024-09-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-09-28 | 2023-10-25 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-09-28 | 2023-10-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-28 | 2023-10-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-28 | 2023-10-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-28 | 2023-10-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-28 | 2023-10-25 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-09-28 | 2023-10-25 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-09-28 | 2023-10-23 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-08-11 | 2023-09-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-11 | 2023-09-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-10 | 2022-06-30 | 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 | 2022-06-10 | 2022-06-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-10 | 2022-06-30 | 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 | 2022-06-10 | 2022-06-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-11 | 2022-03-16 | 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 | 2019-10-09 | 2019-11-05 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-10-09 | 2019-11-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-09 | 2019-11-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-09 | 2019-11-05 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-10-09 | 2019-10-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-10-09 | 2019-10-30 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2019-10-09 | 2019-10-30 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2019-10-09 | 2019-10-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-09 | 2019-10-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-09 | 2019-10-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-10-09 | 2019-10-22 | 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 | 2019-10-09 | 2019-10-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-09 | 2019-10-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-09 | 2019-10-10 | N |
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