CMS Inspection Results for LEGEND OAKS HEALTHCARE AND REHABILITATION CENTER

The Center for Medicare & Medcaid Services (CMS) contracts with each state to conduct inspections once every 9-15 months to assure that certified facilities meet the minimum Medicare and Medicaid quality and performance standards.

• 11/14/2008 Health Survey for LEGEND OAKS HEALTHCARE AND REHABILITATION CENTER

Administration
Deficiency	Scope	Level of Harm
Make sure that nurse aides show they have the skills to be able to care for residents.	Isolated	Minimal harm or potential for actual harm
Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm

 

• 11/13/2008 Fire Safety Survey for LEGEND OAKS HEALTHCARE AND REHABILITATION CENTER

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
portable fire extinguishers.	Widespread	Potential for minimal harm
Emergency Plans and Fire Drills
Deficiency	Scope	Level of Harm
record of quarterly fire drills for each shift under varying conditions.	Pattern	Minimal harm or potential for actual harm

 

• 12/11/2007 Fire Safety Survey for LEGEND OAKS HEALTHCARE AND REHABILITATION CENTER

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
an approved automatic sprinkler system connected to the fire alarm system.	Isolated	Minimal harm or potential for actual harm
Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
Fire Alarm Systems
Deficiency	Scope	Level of Harm
an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm
Smoke Compartmentation and Control
Deficiency	Scope	Level of Harm
walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Isolated	Minimal harm or potential for actual harm

 

• 12/07/2007 Health Survey for LEGEND OAKS HEALTHCARE AND REHABILITATION CENTER

Administration
Deficiency	Scope	Level of Harm
Hire a qualified activities director.	Pattern	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm
Make a complete assessment that covers all questions for areas that are listed in official regulations.	Pattern	Potential for minimal harm
Assess the resident when the resident enters the nursing home, in a timely manner.	Pattern	Potential for minimal harm
Check and update (if needed) each resident's assessment every 3 months.	Pattern	Potential for minimal harm
Keep assessments completed in the preceding 15 months in the resident's active record.	Pattern	Potential for minimal harm
Resident Rights
Deficiency	Scope	Level of Harm
Allow residents to easily see the results of the nursing home's most recent survey.	Pattern	Potential for minimal harm

 

• 02/07/2007 Health Survey for LEGEND OAKS HEALTHCARE AND REHABILITATION CENTER

Nutrition and Dietary
Deficiency	Scope	Level of Harm
Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm

 

• 02/07/2007 Fire Safety Survey for LEGEND OAKS HEALTHCARE AND REHABILITATION CENTER

Smoking Regulations
Deficiency	Scope	Level of Harm
posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Widespread	Potential for minimal harm