Independent · Federal inspection records, searchable
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Nursing Home Violations Public inspection data, searchable
Facility profile · CCN 175078

Legacy At College Hill

71 federal citations on record , including 4 at the Immediate Jeopardy level, and 6 federal enforcement actions totaling $96,031.

Special Focus Status 4 Immediate Jeopardy

Record summary

Federal record · Q1 2026
71
Total citations
48
Last 3 years
8
Actual harm+
6
Federal penalties
$96,031
Total fines
1
Overall ★ rating

Most common violation categories here

Quality of Care18 Medication & Pharmacy12 Resident Rights8 Care Planning7 Administration6

Most common F-tags at this facility

F6894 F8804 F6573 F7563 F7583

Citation history

71 on record
SurveyF-TagViolationSeveritySource
May 21, 2025F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.FComplaint
May 21, 2025F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.DComplaint
May 21, 2025F584Honor 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.EComplaint
Feb 13, 2025F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.FComplaint
Feb 13, 2025F883Develop and implement policies and procedures for flu and pneumonia vaccinations.EComplaint
Feb 13, 2025F880Provide and implement an infection prevention and control program.FComplaint
Feb 13, 2025F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.DComplaint
Feb 13, 2025F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.EComplaint
Feb 13, 2025F761Ensure 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.DComplaint
Feb 13, 2025F758Implement 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.DComplaint
Feb 13, 2025F757Ensure each resident’s drug regimen must be free from unnecessary drugs.DComplaint
Feb 13, 2025F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.DComplaint
Feb 13, 2025F699Provide care or services that was trauma informed and/or culturally competent.DComplaint
Feb 13, 2025F698Provide safe, appropriate dialysis care/services for a resident who requires such services.DComplaint
Feb 13, 2025F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.DComplaint
Feb 13, 2025F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.DComplaint
Feb 13, 2025F625Notify 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.DComplaint
Jul 30, 2024F880Provide and implement an infection prevention and control program.DComplaint
Jul 30, 2024F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.DComplaint
Jul 30, 2024F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.DComplaint
Jul 30, 2024F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.GComplaint
Jul 30, 2024F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DComplaint
Jul 30, 2024F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.DComplaint
May 2, 2023F919Make sure that a working call system is available in each resident's bathroom and bathing area.FComplaint
May 2, 2023F880Provide and implement an infection prevention and control program.FComplaint
May 2, 2023F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyFComplaint
May 2, 2023F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.FComplaint
May 2, 2023F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.FComplaint
May 2, 2023F758Implement 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.EComplaint
May 2, 2023F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.EComplaint
May 2, 2023F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.DComplaint
May 2, 2023F741Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.EComplaint
May 2, 2023F730Observe each nurse aide's job performance and give regular training.DComplaint
May 2, 2023F727Have 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.FComplaint
May 2, 2023F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.FComplaint
May 2, 2023F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.DComplaint
May 2, 2023F700Try 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.EComplaint
May 2, 2023F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.GComplaint
May 2, 2023F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.DComplaint
May 2, 2023F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.DComplaint
May 2, 2023F646Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.DComplaint
May 2, 2023F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.DComplaint
May 2, 2023F610Respond appropriately to all alleged violations.LComplaint
May 2, 2023F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.KComplaint
May 2, 2023F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.LComplaint
May 2, 2023F584Honor 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.FComplaint
May 2, 2023F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.DComplaint
May 2, 2023F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.DStandard
Apr 10, 2023F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.JComplaint
Oct 5, 2021F880Provide and implement an infection prevention and control program.DStandard
Oct 5, 2021F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyFStandard
Oct 5, 2021F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.FStandard
Oct 5, 2021F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.FStandard
Oct 5, 2021F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.FStandard
Oct 5, 2021F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.FStandard
Oct 5, 2021F761Ensure 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.DStandard
Oct 5, 2021F758Implement 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.DStandard
Oct 5, 2021F757Ensure each resident’s drug regimen must be free from unnecessary drugs.DStandard
Oct 5, 2021F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.DStandard
Oct 5, 2021F727Have 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.FStandard
Oct 5, 2021F695Provide safe and appropriate respiratory care for a resident when needed.DStandard
Oct 5, 2021F692Provide enough food/fluids to maintain a resident's health.GStandard
Oct 5, 2021F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.DStandard
Oct 5, 2021F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.GStandard
Oct 5, 2021F677Provide care and assistance to perform activities of daily living for any resident who is unable.DStandard
Oct 5, 2021F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.DStandard
Oct 5, 2021F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.DStandard
Oct 5, 2021F625Notify 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.DStandard
Oct 5, 2021F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.DStandard
Oct 5, 2021F574The resident has the right to receive notices in a format and a language he or she understands.DStandard
Oct 5, 2021F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.DStandard

Federal enforcement history

Federal regulators have imposed 6 enforcement actions against this facility, including 4 civil money penalties totaling $96,031 and 2 payment-denial actions spanning 26 days.

DateTypeFinePayment denial
Mar 12, 2025Fine$8,281—
Mar 12, 2025Payment Denial—Mar 29, 2025 · 10 days
Jul 30, 2024Fine$34,775—
May 2, 2023Fine$43,660—
May 2, 2023Payment Denial—May 30, 2023 · 16 days
Apr 10, 2023Fine$9,315—
About this record A citation is a finding by a state survey team working under federal contract. It is not a court judgment. The description above is drawn verbatim from federal public datasets. Facilities have the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.

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