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Legacy Nursing at St. Christina: Feeding Tube Failures - LA
The incident occurred on the night of August 17, 2025, at Legacy Nursing at St....
Latest reports, citations, and penalties from CMS data
The incident occurred on the night of August 17, 2025, at Legacy Nursing at St....
Woodland Post-Acute failed to process the refund for Resident 1, who died with encephalopathy after living at the facility since 2020....
The resident, identified as R6 in inspection records, showed inspectors the dirty filter on August 18, removing it from the machine sitting on the desk....
According to state inspection records, the aide was wheeling the resident through a hallway when the resident slapped the aide on the left side of their face....
Resident 5 at Crossings at East Lake of Journey has spastic quadriplegia cerebral palsy and severe cognitive impairment....
Resident 1 was admitted to the facility in February 2023....
The violations came to light during a complaint inspection in August....
The nursing assistant began feeling unwell on Saturday, August 16, experiencing body aches, throat pain, and congestion....
The resident was discharged 13 days later....
The incident occurred after Resident #1 had been exhibiting wandering and exit-seeking behaviors since August 5, according to nursing progress notes....
The plan also required staff to "re-evaluate to extend or heal" the abrasion....
The facility's own policy, revised in April, explicitly prohibits this arrangement when the average daily occupancy exceeds 60 residents....
The facility's interdisciplinary team met on January 9, 2025, to discuss Resident #1's care needs....
Federal inspectors found the facility failed to provide appropriate care and services according to the resident's plan of care....
LPN #1 began wound care for Resident #2 at 9:26 a.m., properly donning gloves and a gown before positioning the resident and removing the current dressing....
The male resident, identified in records as R4, had already been flagged twice this year for inappropriate sexual behavior toward female residents....
The omission violated the facility's own policy requiring comprehensive care plans to include all services needed to maintain residents' well-being....
Their allergy to latex was documented in an allergy tab dated March 5....
The resident was back at the facility within 24 hours after going to a local hospital due to a fall at home....
His personal account funds didn't arrive in the mail until February 5, 2025....