Provider Name: THE LEGACY MIDTOWN PARK
Address: 8280 MANDERVILLE LANE, DALLAS, TX 75231
Phone: (972) 468-6207
County: Anderson (000)
Ownership Type: For profit - Corporation
Certified Beds: 54
Average Residents Per Day: 47.1 ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: THE LEGACY MIDTOWN PARK INC
First Approved Date: July 31, 2020
Affiliated Entity: ()
Retirement Community: Y, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: Resident
Sprinkler System Status: Yes
Overall Rating: 5 ()
Health Inspection Rating: 5 ()
QM Rating: 5 ()
Long Stay QM Rating: 4 ()
Short Stay QM Rating: 5 ()
Staffing Rating: 4 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 3.31533, LPN Staff Hours Per Day: 1.2293, RN Staff Hours Per Day: 0.9625, Licensed Staff Hours Per Day: 2.1918
Total Nurse Staff Hours Per Day, per resident: 5.50721
Weekend Nurse Staff Hours: 4.93912, Weekend RN Staff Hours: 0.8301
PT Staff Hours Per Day, per resident: 0.2123
Nurse Staff Turnover: 64.0, Nurse Turnover Note:
RN Turnover: 80.0, RN Turnover Note:
Admin Left Number: 0, Admin Turnover Note:
Case Mix Nurse Aide Hours Per Day, per resident: 1.9156, Case Mix LPN Hours Per Day: 0.7008, Case Mix RN Hours Per Day: 0.3331
Adjusted Nurse Aide Hours Per Day, per resident: 3.52587, Adjusted LPN Hours Per Day: 1.2944, Adjusted RN Hours Per Day: 1.0887
Total Adjusted Nurse Hours Per Day, per resident: 5.88521
Adjusted Weekend Nurse Hours Per Day, per resident: 5.27812
Health Survey Dates and Scores: Cycle 1: 2023-07-20 (Score: 12), Cycle 2: 2022-06-09 (Score: 20), Cycle 3: 2020-07-31 (Score: 0)
Total Weighted Health Score: 12.667
Reported Incidents: 0, Substantiated Complaints: 0
Infection Control Citations: 1
Fines and Penalties: Number of Fines: 9, Total Fines in Dollars: 43810.40, Payment Denials Number: 0, Total Penalties Number: 9
Location and GPS: 8280 MANDERVILLE LANE,DALLAS,TX,75231 (32.8941, -96.766)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: 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.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-07-24
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-07-24
Type: Health, Deficiency: Provide safe and appropriate respiratory care for a resident when needed.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-06-21
Type: Health, Deficiency: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-06-21
Type: Health, Deficiency: Provide enough food/fluids to maintain a resident's health.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-06-21
Type: Health, Deficiency: Develop and implement policies and procedures for flu and pneumonia vaccinations.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-06-21
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Fire Safety, Tag: 0372, Version: New
Description: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-08-08
Type: Fire Safety, Tag: 0374, Version: New
Description: Install smoke barrier doors that can resist smoke for at least 20 minutes.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-07-19
Type: Fire Safety, Tag: 0918, Version: New
Description: Have generator or other power source capable of supplying service within 10 seconds.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-06-17