LEGACY AT COLLEGE HILL
Inspection History Overview
Health Violations by Year
2025 12 violations
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Provide care or services that was trauma informed and/or culturally competent.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Ensure each residentβs drug regimen must be free from unnecessary drugs.
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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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.
Provide and implement an infection prevention and control program.
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
2024 6 violations
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide appropriate treatment and care according to orders, residentβs preferences and goals.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Provide and implement an infection prevention and control program.
2023 26 violations
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Respond appropriately to all alleged violations.
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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.
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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.
Observe each nurse aide's job performance and give regular training.
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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.
2021 28 violations
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
The resident has the right to receive notices in a format and a language he or she understands.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Notify the resident or the residentβs representative in writing how long the nursing home will hold the residentβs bed in cases of transfer to a hospital or therapeutic leave.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide enough food/fluids to maintain a resident's health.
Provide safe and appropriate respiratory care for a resident when needed.
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.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Ensure each residentβs drug regimen must be free from unnecessary drugs.
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.
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.
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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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.
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
2020 1 violations
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
2019 6 violations
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Ensure each residentβs drug regimen must be free from unnecessary drugs.
2017 14 violations
Give residents a notice of rights, rules, services and charges.
Send unopened mail from residents and promptly deliver unopened mail to residents.
Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care.
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Hire sufficient dietary support personnel.
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.
Store, cook, and serve food in a safe and clean way.
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
Have a program that investigates, controls and keeps infection from spreading.
Allow residents the right to participate in the planning or revision of care and treatment.
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Use a registered nurse at least 8 hours a day, 7 days a week.
Detailed Inspection Reports
No detailed inspection reports available yet. Check back soon as we're processing new reports daily.
Fines and Penalties by Year
2025 2 penalties totaling $12,740
2021 3 penalties totaling $69,153
2020 1 penalties totaling $6,923
Fire Safety Deficiencies
No description available