Legacy Healthcare Center

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Respond appropriately to all alleged violations.

Reasonably accommodate the needs and preferences of each resident.

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

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.

Post nurse staffing information every day.

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Provide and implement an infection prevention and control program.

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Have policies on smoking.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

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.

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Assure that each resident’s assessment is updated at least once every 3 months.

PASARR screening for Mental disorders or Intellectual Disabilities

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Provide activities to meet all resident's needs.

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

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.

Provide safe and appropriate respiratory care for a resident when needed.

Provide safe, appropriate dialysis care/services for a resident who requires such services.

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.

Post nurse staffing information every day.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Ensure medication error rates are not 5 percent or greater.

Reasonably accommodate the needs and preferences of each resident.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Ensure each resident receives an accurate assessment.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Ensure the activities program is directed by a qualified professional.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Provide and implement an infection prevention and control program.

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Provide and implement an infection prevention and control program.

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Provide and implement an infection prevention and control program.

Provide and implement an infection prevention and control program.

Reasonably accommodate the needs and preferences of each resident.

Honor the resident's right to organize and participate in resident/family groups in the facility.

The resident has the right to receive notices in a format and a language he or she understands.

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

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.

PASARR screening for Mental disorders or Intellectual Disabilities

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

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.

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.

Provide safe, appropriate pain management for a resident who requires such services.

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

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.

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.

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Provide and implement an infection prevention and control program.

Reasonably accommodate the needs and preferences of each resident.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Provide and implement an infection prevention and control program.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Prepare residents for a safe transfer or discharge from the nursing home.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Provide activities to meet all resident's needs.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

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.

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

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.

Have enough outside ventilation via a window or mechanical ventilation, or both.

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

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.

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Give the resident's representative the ability to exercise the resident's rights.

Reasonably accommodate the needs and preferences of each resident.

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.

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.

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Provide activities to meet all resident's needs.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

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.

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.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Implement a program that monitors antibiotic use.

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.

Reasonably accommodate the needs and preferences of each resident.

Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Have a program that investigates, controls and keeps infection from spreading.

1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews.

Allow residents to easily view the results of the nursing home's most recent inspection.

Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.

Reasonably accommodate the needs and preferences of each resident.

Ensure services provided by the nursing facility meet professional standards of quality.

Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.

Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.

Store, cook, and serve food in a safe and clean way.

Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.

Keep all essential equipment working safely.

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Give or get quality laboratory services/tests in a timely manner to meet the needs of residents.

Keep accurate, complete and organized clinical records on each resident that meet professional standards.

Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.

Ensure services provided by the nursing facility meet professional standards of quality.