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Deficiency Records for Legacy at College Hill
View the most recent health deficiencies and inspection results for Legacy at College Hill. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Legacy at College Hill. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| 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. | Health | 2025-05-21 | 2025-06-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-05-21 | 2025-06-20 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2025-05-21 | 2025-06-20 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2025-02-13 | 2025-04-08 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2025-02-13 | 2025-04-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-02-13 | 2025-04-08 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2025-02-13 | 2025-04-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2025-02-13 | 2025-04-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2025-02-13 | 2025-04-07 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2025-02-13 | 2025-04-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-02-13 | 2025-04-07 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2025-02-13 | 2025-04-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2025-02-13 | 2025-04-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2025-02-13 | 2025-04-07 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2025-02-13 | 2025-04-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2025-02-13 | 2025-04-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2025-02-13 | 2025-04-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2025-02-13 | 2025-04-07 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2025-02-13 | 2025-04-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2025-02-13 | 2025-04-07 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2025-02-13 | 2025-03-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2025-02-13 | 2025-03-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-02-13 | 2025-03-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-02-13 | 2025-03-12 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2025-02-13 | 2025-03-07 | Y |
| 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. | Health | 2025-02-13 | 2025-03-07 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2025-02-13 | 2025-03-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-02-13 | 2025-03-07 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2025-02-13 | 2025-03-07 | Y |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2025-02-13 | 2025-03-07 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2025-02-13 | 2025-03-07 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2025-02-13 | 2025-03-07 | Y |
| 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. | Health | 2025-02-13 | 2025-03-07 | Y |
| 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 | 2025-02-13 | 2025-03-07 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-02-13 | 2025-03-07 | Y |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2025-02-13 | 2025-03-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-02-13 | 2025-03-07 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2025-02-13 | 2025-03-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-07-30 | 2024-08-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-07-30 | 2024-08-23 | Y |
| 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 | 2024-07-30 | 2024-08-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-07-30 | 2024-08-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-30 | 2024-08-23 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-07-30 | 2024-08-23 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-05-02 | 2023-07-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-02 | 2023-07-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-02 | 2023-07-26 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-02 | 2023-07-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-02 | 2023-07-26 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-05-02 | 2023-07-26 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2023-05-02 | 2023-07-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-02 | 2023-07-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-02 | 2023-07-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-02 | 2023-07-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-02 | 2023-07-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-05-02 | 2023-07-26 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-05-02 | 2023-07-26 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-05-02 | 2023-07-26 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-05-02 | 2023-07-26 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-05-02 | 2023-07-26 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-05-02 | 2023-07-26 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-05-02 | 2023-07-26 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-05-02 | 2023-07-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-02 | 2023-07-26 | N |
| 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. | Health | 2023-05-02 | 2023-06-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-02 | 2023-06-15 | Y |
| 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. | Health | 2023-05-02 | 2023-06-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-02 | 2023-06-15 | Y |
| 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 | 2023-05-02 | 2023-06-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-02 | 2023-06-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-02 | 2023-06-15 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-05-02 | 2023-06-15 | Y |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2023-05-02 | 2023-06-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-02 | 2023-06-15 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-05-02 | 2023-06-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-02 | 2023-06-15 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-05-02 | 2023-06-15 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-05-02 | 2023-06-15 | Y |
| 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. | Health | 2023-05-02 | 2023-06-15 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-05-02 | 2023-06-15 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2023-05-02 | 2023-06-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-02 | 2023-06-15 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-05-02 | 2023-06-15 | Y |
| 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. | Health | 2023-05-02 | 2023-06-15 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-02 | 2023-06-15 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-05-02 | 2023-06-15 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-05-02 | 2023-06-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-02 | 2023-06-15 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-05-02 | 2023-06-15 | Y |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-05 | 2021-12-15 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-10-05 | 2021-12-15 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-10-05 | 2021-12-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-10-05 | 2021-12-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-05 | 2021-12-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-10-05 | 2021-12-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-05 | 2021-12-15 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-10-05 | 2021-12-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-10-05 | 2021-12-15 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-10-05 | 2021-12-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-10-05 | 2021-12-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-05 | 2021-12-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-05 | 2021-12-15 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-10-05 | 2021-12-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-10-05 | 2021-12-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-10-05 | 2021-12-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-10-05 | 2021-12-15 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-10-05 | 2021-12-15 | N |
| Use approved construction type or materials. | Fire Safety | 2021-10-05 | 2021-12-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-10-05 | 2021-12-15 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-10-05 | 2021-12-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-10-05 | 2021-12-15 | N |
| 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. | Health | 2021-10-05 | 2021-11-08 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-10-05 | 2021-11-08 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-10-05 | 2021-11-08 | N |
| 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. | Health | 2021-10-05 | 2021-11-08 | 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 | 2021-10-05 | 2021-11-08 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-10-05 | 2021-11-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-05 | 2021-11-08 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | Health | 2021-10-05 | 2021-11-08 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-10-05 | 2021-11-08 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-10-05 | 2021-11-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-05 | 2021-11-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-05 | 2021-11-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-05 | 2021-11-08 | 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 | 2021-10-05 | 2021-11-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-05 | 2021-11-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-05 | 2021-11-08 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-10-05 | 2021-11-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-05 | 2021-11-08 | N |
| 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. | Health | 2021-10-05 | 2021-11-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-10-05 | 2021-11-08 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2021-10-05 | 2021-11-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-05 | 2021-11-08 | N |