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Deficiency Records for The Legacy at Willow Bend
A list of the most recent deficiencies for The Legacy at Willow Bend. 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 at Willow Bend. 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? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-14 | 2023-10-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-14 | 2023-10-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-14 | 2023-10-14 | 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 | 2023-09-14 | 2023-10-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-14 | 2023-10-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-14 | 2023-10-14 | Y |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-09-14 | 2023-10-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-14 | 2023-03-31 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-08-11 | 2022-09-16 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2022-08-11 | 2022-09-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-11 | 2022-09-16 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-08-11 | 2022-09-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-11 | 2022-09-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-08-11 | 2022-09-16 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-08-11 | 2022-09-16 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-02-17 | 2022-03-17 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-17 | 2022-03-17 | Y |
| 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 | 2021-06-17 | 2021-07-28 | 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 | 2021-06-17 | 2021-07-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-17 | 2021-07-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-06-17 | 2021-07-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-17 | 2021-07-26 | 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 | 2021-06-17 | 2021-07-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-17 | 2021-07-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-17 | 2021-07-26 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2021-06-17 | 2021-07-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-06-17 | 2021-07-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-17 | 2021-07-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-06-17 | 2021-07-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-17 | 2021-07-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-06-17 | 2021-07-26 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2021-06-17 | 2021-07-26 | N |
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