A list of the most recent deficiencies for Legacy at St Christina. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-19 | 2024-02-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-19 | 2023-12-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-16 | 2023-12-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-16 | 2023-12-08 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-11-16 | 2023-12-08 | N |
| 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 | 2023-11-16 | 2023-12-08 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-11-16 | 2023-12-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-16 | 2023-12-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-16 | 2023-12-08 | 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 | 2023-11-16 | 2023-12-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-16 | 2023-12-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-16 | 2023-12-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-16 | 2023-12-08 | 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 | 2023-11-16 | 2023-12-08 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-11-16 | 2023-12-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-16 | 2023-12-08 | N |
| Dispose of garbage and refuse properly. | Health | 2023-11-16 | 2023-12-08 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-11-16 | 2023-12-08 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-03 | 2023-10-27 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-08-03 | 2023-08-25 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-03 | 2023-08-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-25 | 2023-06-23 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-25 | 2023-06-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-27 | 2023-05-05 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-03-29 | 2023-04-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-29 | 2023-04-05 | 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 | 2023-03-29 | 2023-04-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-01-13 | 2023-02-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-13 | 2023-02-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-13 | 2023-02-03 | 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 | 2023-01-13 | 2023-02-03 | Y |
| Dispose of garbage and refuse properly. | Health | 2023-01-13 | 2023-02-03 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-01-13 | 2023-02-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-13 | 2023-02-03 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-12-14 | 2022-12-15 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-10-19 | 2022-11-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-19 | 2022-11-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-19 | 2022-11-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-19 | 2022-11-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-19 | 2022-11-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-19 | 2022-11-11 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-09-07 | 2022-09-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-07 | 2022-09-30 | 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 | 2022-09-07 | 2022-09-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-19 | 2022-05-06 | Y |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2022-04-19 | 2022-05-06 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-03 | 2022-03-21 | 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 | 2022-03-03 | 2022-03-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-03 | 2022-03-21 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-03 | 2022-03-21 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-10-15 | 2021-12-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-10-15 | 2021-11-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-15 | 2021-11-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-10-15 | 2021-11-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-15 | 2021-11-12 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-10-15 | 2021-11-12 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-10-15 | 2021-11-12 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-10-15 | 2021-11-12 | N |
| 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 | 2021-10-15 | 2021-11-12 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2021-10-15 | 2021-11-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-10-15 | 2021-11-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-15 | 2021-11-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-15 | 2021-11-12 | N |
| Provide activities to meet all resident's needs. | Health | 2021-10-15 | 2021-11-12 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-10-15 | 2021-11-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-15 | 2021-11-12 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-10-15 | 2021-11-12 | N |
| Post nurse staffing information every day. | Health | 2021-10-15 | 2021-11-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-15 | 2021-11-12 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-10-15 | 2021-11-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-15 | 2021-11-12 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2021-10-15 | 2021-11-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-11-17 | Not Fixed | N |
