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Deficiency Records for Legend Oaks Healthcare and Rehabilitation - West S

A list of the most recent deficiencies for Legend Oaks Healthcare and Rehabilitation - West S. 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 Legend Oaks Healthcare and Rehabilitation - West S. 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?
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-04-12 2024-04-15 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-04-12 2024-04-15 Y
Assure that each resident?s assessment is updated at least once every 3 months. Health 2023-09-15 2023-10-12 N
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Health 2023-09-15 2023-10-12 N
PASARR screening for Mental disorders or Intellectual Disabilities Health 2023-09-15 2023-10-12 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-09-15 2023-10-12 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-09-15 2023-10-12 N
Provide and implement an infection prevention and control program. Health 2022-07-15 2022-08-11 N
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 2022-07-15 2022-07-22 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-04-21 2022-05-04 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-02-09 2022-03-03 Y
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2021-04-14 2021-05-14 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2021-04-14 2021-05-14 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2021-04-14 2021-05-14 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2021-04-14 2021-05-14 N
Provide and implement an infection prevention and control program. Health 2021-04-16 2021-05-12 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2021-04-16 2021-05-05 N
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Health 2021-04-16 2021-05-05 N

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