Inspection Results » Legacy at Herington

Health Inspection on October 29, 2018 ^[1]

1. Isolated: Actual harm that is not immediate jeopardy

   • Provide enough food/fluids to maintain a resident's health. (Corrected 2018-11-21)

2. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2018-11-21)
   • Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (Corrected 2018-11-21)
   • Keep all essential equipment working safely. (Corrected 2018-11-21)
   • Administer the facility in a manner that enables it to use its resources effectively and efficiently. (Corrected 2018-11-21)
   • Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (Corrected 2018-11-21)
   • 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. (Corrected 2018-11-21)
   • Put firmly secured handrails on each side of hallways. (Corrected 2018-11-21)
   • Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. (Corrected 2018-11-21)

3. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Provide care and assistance to perform activities of daily living for any resident who is unable. (Corrected 2018-11-21)
   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2018-11-21)

4. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Provide routine and 24-hour emergency dental care for each resident. (Corrected 2018-11-21)
   • 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 ne (Corrected 2018-11-21)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2018-11-21)
   • Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. (Corrected 2018-11-21)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-11-21)
   • Respond appropriately to all alleged violations. (Corrected 2018-11-21)
   • 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. (Corrected 2018-11-21)
   • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected 2018-11-21)