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Deficiency Records for Legacies Nursing and Rehabilitation

A list of the most recent deficiencies for Legacies 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 Legacies 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?
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2024-01-23 2024-03-01 N
Provide properly protected cooking facilities. Fire Safety 2024-01-23 2024-03-01 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-01-23 2024-03-01 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2024-01-23 2024-03-01 N
Have proper medical gas storage and administration areas. Fire Safety 2024-01-23 2024-03-01 N
Allow residents to self-administer drugs if determined clinically appropriate. Health 2023-12-20 2024-01-16 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 2023-12-20 2024-01-16 N
Ensure that residents are free from significant medication errors. Health 2023-12-20 2024-01-16 N
Provide and implement an infection prevention and control program. Health 2023-12-20 2024-01-16 N
Make sure that a working call system is available in each resident's bathroom and bathing area. Health 2023-12-20 2024-01-16 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-12-20 2024-01-16 Y
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Health 2023-12-20 2024-01-16 Y
Have a policy regarding use and storage of foods brought to residents by family and other visitors. Health 2023-12-20 2024-01-16 Y
Provide safe and appropriate respiratory care for a resident when needed. Health 2022-11-02 2022-12-01 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 2022-11-02 2022-12-01 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-11-02 2022-12-01 N
Have a policy regarding use and storage of foods brought to residents by family and other visitors. Health 2022-11-02 2022-12-01 N
Provide and implement an infection prevention and control program. Health 2022-11-02 2022-12-01 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2022-11-03 2022-12-01 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2021-09-30 2021-11-15 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2021-09-30 2021-11-15 N
PASARR screening for Mental disorders or Intellectual Disabilities Health 2021-09-21 2021-10-20 N
Provide enough food/fluids to maintain a resident's health. Health 2021-09-21 2021-10-20 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2021-09-21 2021-10-20 N

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