A list of the most recent deficiencies for Legacy at College Hill. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-05-24 | 2023-07-26 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-05-24 | 2023-07-26 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-05-24 | 2023-07-26 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-05-24 | 2023-07-26 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-05-24 | 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 | 2023-05-24 | 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 | 2023-05-24 | 2023-07-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-24 | 2023-07-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-24 | 2023-07-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-24 | 2023-07-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-24 | 2023-07-26 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2023-05-24 | 2023-07-26 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-05-24 | 2023-07-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-24 | 2023-07-26 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-24 | 2023-07-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-24 | 2023-07-26 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-05-24 | 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 | 2023-05-24 | 2023-07-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-24 | 2023-07-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-24 | 2023-07-26 | 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 | 2023-05-02 | 2023-06-15 | N |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-10 | 2023-04-10 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-11-16 | 2021-12-15 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-11-16 | 2021-12-15 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-11-16 | 2021-12-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-11-16 | 2021-12-15 | N |
| Use approved construction type or materials. | Fire Safety | 2021-11-16 | 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 | 2021-11-16 | 2021-12-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-11-16 | 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 | 2021-11-16 | 2021-12-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-11-16 | 2021-12-15 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-11-16 | 2021-12-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-16 | 2021-12-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-11-16 | 2021-12-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-16 | 2021-12-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-11-16 | 2021-12-15 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-11-16 | 2021-12-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-11-16 | 2021-12-15 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-11-16 | 2021-12-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-16 | 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 | 2021-11-16 | 2021-12-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-16 | 2021-12-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-11-16 | 2021-12-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-11-16 | 2021-12-15 | 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | 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 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 enough food/fluids to maintain a resident's health. | 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 |
| 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 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 care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-22 | 2021-07-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-22 | 2021-07-30 | 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 | 2021-07-22 | 2021-07-30 | Y |
| Request a waiver if it can't meet the nurse staffing requirements. | Health | 2021-07-22 | 2021-07-30 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-07-22 | 2021-07-30 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-07-22 | 2021-07-30 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-12-16 | 2020-01-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-12-16 | 2020-01-14 | 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 | 2019-12-16 | 2020-01-14 | N |
| 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. | Health | 2019-12-16 | 2020-01-14 | 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 | 2019-12-16 | 2020-01-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-12-16 | 2020-01-14 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-10-21 | 2019-11-19 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-10-21 | 2019-11-19 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-10-21 | 2019-11-19 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-10-21 | 2019-11-19 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-10-21 | 2019-11-19 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-10-21 | 2019-11-19 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-10-21 | 2019-11-19 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-10-21 | 2019-11-19 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-10-21 | 2019-11-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-10-21 | 2019-11-19 | 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 | 2019-10-21 | 2019-11-19 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2019-10-21 | 2019-11-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-21 | 2019-11-19 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-10-21 | 2019-11-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-10-21 | 2019-11-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-21 | 2019-11-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-10-21 | 2019-11-19 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-10-21 | 2019-11-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-10-21 | 2019-11-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-10-21 | 2019-11-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-21 | 2019-11-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-21 | 2019-11-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-10-21 | 2019-11-19 | N |
