Legacy Nursing at St. Christina

In the surveyor’s words

From the most serious findings on record at Legacy Nursing at St. Christina, in the surveyor’s own words.

• Immediate jeopardy, patternF684Jan 13, 2023

  Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and in accordance with person-centered care plans by failing to: 1. Ensure two staff were available, as per care plan, to transfer Resident #6 from the floor back to his mattress. As a result, Resident #6 lay on the cold, tiled floor for an extended period of time; 2. Ensure Resident #24 did not pocket and spit out medications administered to him as ordered; 3. Ensure staff provided supervision/assistance of one person, as per care plan, for Resident #4 when he verbalized the need to use the restroom. As a result, Resident #4 urinated on himself; 4. […]

• Immediate jeopardy, patternF725Jan 13, 2023

  Based on observation, record review and interview, the facility failed to provide sufficient nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promoted each resident's rights, physical, mental and psychosocial well-being as determined by resident assessments and individual plans of care. The facility failed to ensure there was sufficient staff to provide supervision and care and services for 20 Residents who resided on a locked, secure unit, and had psychiatric and/or behavioral diagnoses: #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23 and #24. […]

• Immediate jeopardy, patternF835Jan 13, 2023

  Based on observation, interview and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to obtain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident. The facility failed to ensure residents received treatment and care in accordance with professional standards of practice and in accordance with person-centered care plans, and failed to have an effective system in place to ensure there was sufficient staffing to meet the safety and care needs for 20 residents who had psychiatric and behavioral diagnoses (#4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23 and #24). […]

• Actual harm, isolatedF600Sep 30, 2025

  Based on interview, observation, and record review the facility failed to ensure a resident's right to be free from resident to resident physical abuse for 1 (Resident #2) of 4 (Resident #1, Resident #2, Resident #3, Resident #4) sampled residents. This deficient practice resulted in Actual Harm for Resident #2 on 09/21/2025 at 3:30 pm, when Resident #2 was hit by Resident #4 in the face with his left fist. Resident #2 was sent to a local emergency department where he received treatment for a facial contusion. Findings: Review of the facility policy titled Abuse Prevention and Prohibition revealed in part. Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. […]

• Actual harm, isolatedF684Feb 27, 2025

  Based on observations, interviews and record reviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice and the resident's person centered plan of care, for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) residents sampled for quality of care. This deficient practice resulted in a delay in treatment of a wound to Resident #3's right elbow, and development of cellulitis of the right elbow that required antibiotic treatment. This failed practice resulted in an actual harm for Resident #3 on 02/26/2025 at 2:26 p.m., when the resident was observed to have a wound to his right elbow, with edema and erythema noted. […]