Horizon Post Acute

the facility had no minutes or meetings for the months of May 2025 through May 2026.On 06/02/26 at

owners acquired the facility. R3 stated the Administrative Staff A conducted a meeting in 02/26. R3 stated she could not remember the actual day of the meeting. R3 stated the activities directors used to facilitate the Resident Council meeting but said the facility had several turnovers in the activity department, and a Resident Council meeting had not occurred.On 06/03/26 at 01:31 PM, Administrative Nurse D stated Administrative Staff A had held a meeting with the residents.

She stated the facility had turnover in the activity department.

She stated she was unsure if the meetings were happening.On 6/03/26 at 02:11 PM, Administration Staff A stated she had arranged and assisted the residents with one resident council meeting in the past three months.

She stated she did not know where the minutes to that meeting could be found.

She stated she had not had many grievances filed since she had become the administrator at the facility.The facility's Resident Council Meeting policy dated 02/01/26 documented the facility supports the rights of residents to organize and participate in resident groups, including a Resident Council.

This policy provides guidance to promote structure, order, and productivity in these group meetings.

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Legacy at College Hill 5005 E 21st Street North Wichita, KS 67208

Findings included:- On

During an interview on 06/03/2026 at 01:40 PM, Administrative Staff D stated that there is a survey book for the facility, but she did not know where it was.

The facility was unable to provide a policy related to past survey results availability.

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Legacy at College Hill 5005 E 21st Street North Wichita, KS 67208

06/02/26 at 07:55 AM, Certified Medication Aide (CMA) R left her locked medication cart unattended

on the screen. On 06/02/26 at 07:57 AM, CMA R returned to her medication cart. CMA R confirmed she was assigned to that medication cart. CMA R then stated she was not positive if the screen needed to be locked or hidden when she was not at the cart. On 06/03/26 at 09:26 AM, Licensed Nurse (LN) I stated that medication carts and laptop screens should be locked at any time a medication aide or nurse walked away from the cart. On 06/03/26 at 01:32 PM, Administrative Nurse D confirmed that the cart and laptop screen should be locked when the staff member walked away from the cart.

The facility's Confidentiality of Personal and Medical Records policy dated 02/01/26 documented this facility honors the resident's right to secure and confidential personal and medical records.

This included the right to confidentiality of all information contained in a resident's records, regardless of the form of storage or location of the record.

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Legacy at College Hill 5005 E 21st Street North Wichita, KS 67208

During an interview on 06/02/2026 at 08:25 AM, Maintenance V stated that they do not ever change the air conditioner filters, but they do clean them once a week. He said he would ask if it is charted somewhere, as he does not chart it. He stated that he worked with housekeeping to make sure the cleaning got done, and that he would check with housekeepingOn 06/02/2026 at 08:53 AM, Maintenance V stated staff just implemented a checkoff sheet for housekeeping staff to document on when the cleaning was done.

During an interview on 06/03/2026 at 10:15 AM, Maintenance V stated that he received an alert on his phone for issues that needed addressed and it would be addressed immediately. He stated the vents with black substance on them were to be cleaned and monitored every day to make sure it would be gone. He stated that staff have a meeting every two weeks for concerns.

Maintenance V stated the vents were addressed by housekeeping.

During an interview on 06/03/2026 at 01:40 PM, Administrative Nurse D stated that the expectation for staff to identify cleaning needs or broken equipment should be addressed immediately with See something, say something by informing maintenance when there is an issue or staff is to clean it themselves when they notice it.The facility policy The Safe and Homelike Environment dated 02/01/2026 documented that in accordance with residents' rights, the facility would provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.

That included ensuring that the resident would receive care and services safely and that the physical layout of the facility, both inside and outside, maximized resident independence and does not pose a safety risk.

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Legacy at College Hill 5005 E 21st Street North Wichita, KS 67208

Findings included:- R22's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), posttraumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).The Quarterly Minimum Data Set (MDS) dated 04/15/26 documented a Brief Interview of Mental Status (BIMS) score of nine, which indicated moderately impaired cognition.

The MDS documented R22 required staff assistance for setup and cleanup during bathing. R22's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 10/16/25, documented she had a cognitive deficit and visual hallucinations. R22's Care Plan documented the following interventions: 02/04/26 - Staff would encourage ongoing family involvement.Staff would invite her family to attend special events, activities, and meals.Staff would invite and encourage her to attend activities, offer assistance for locomotion as indicated.

Staff would invite her to all scheduled activities.

Staff would provide her with in- room activities as needed and desired.Staff would provide her with social interaction opportunities.

She enjoyed visits from her family and spending time with her dog.

She enjoyed word games, trivia bingo, and ice cream socials. R22's EMR under the MISC tab revealed a PASSAR I, dated 09/11/24, which documented she was indicated for further evaluation. R22's clinical record lacked evidence further evaluation (PASSAR II) was provided.The facility was unable to provide evidence a PASSAR Level II was requested and provided as indicated for R22 as requested on 06/03/26 at 08:15 AM.On 06/02/26 at 08:42 AM, R22 sat in the dining room with a smoker apron on.

She sat and watched TV.

Her hair was oily and stringy.On 06/03/26 at 01:33 PM, Administrative Nurse D stated the social service department was unable to find any documentation that level two PASSAR assessment was completed as indicated.

The facility's Resident Assessment - Coordination with PASARR Program policy dated 02/01/26 documented the facility coordinated assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs.

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Legacy at College Hill 5005 E 21st Street North Wichita, KS 67208

reviewed, and revised by a team of health professionals.

observation, record review, and interviews, the facility failed to revise Resident (R) 5's Care Plan to

particularly the bladder, for removing fluid).

Findings Included:- R5's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), major depressive disorder (major mood disorder that causes persistent feelings of sadness), neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin.R5's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition.

The MDS documented R5 had an impairment of the extremities on both sides of his lower body.

The MDS documented R5 needed setup or cleanup assistance with eating and oral hygiene, and dependent on staff for toileting, bathing, and dressing.

The MDS documented R5 had a Foley catheter during the observation period.R5's Urinary Incontinence/Indwelling Catheter Care Area Assessment (CAA) dated 03/09/26 documented R5 triggered for alteration in elimination and the need for an indwelling catheter due to activities of daily living (ADLs).

The CAA documented assistance was required with toileting, perineal care, use of a bed pan for bowel elimination needs, and indwelling catheter care, therefore placing him at risk for alterations in elimination needs.R5's Care Plan documented:02/04/26 - R5 was incontinent with bowels and risk for impaired skin, rashes, and irritation in the peri-area.

Staff were to check R5 every two hours and assist him with toileting as needed.

Staff were to keep R5's call light within his reach to use to notify nursing if R5 needed assistance with toileting or incontinence episodes.

Staff to provide loose fitting, easy to remove clothing.R5's Care Plan lacked staff direction for the care of R5's urinary catheter.R5's EMR revealed the following physician orders:Indwelling urinary catheter irrigate with 60 milliliters (mls) of normal saline every shift for catheter care.Complete catheter care, hang catheter to dependent drainage, and keep inside a dignity bag, chart output every shift, every shift for urine retention.On 06/01/26 at 08:10 AM, R5 laid in his bed with his eyes shut. R5's urinary catheter bag was three fours full of yellow urine and hung from R5's bed, R5's catheter tubing was placed under his right leg, and the bag was not secured to the bed, it was dangling from the bed. R5's bag was just dangling. R5 did not have a dignity bag.On 06/03/26 at 09:51 AM, Certified Nurse Aide (CNA) Q stated he would know how to care for R5's urinary catheter by the ADL log located at the nurse's desk. He stated he was unsure of access to the resident's care plan, the CNA's used the logs at the nurse's desk.On 06/03/26 at 09:36 AM, Licensed Nurse (LN) I stated she was unsure of who placed the urinary catheters on the residents care planOn 06/03/26 at 01:31 PM, Administrative Nurse D stated the urinary catheter should be placed on the residents care plan.The facility's Care Plan Revisions Upon Status Change dated 02/01/26 documented It was the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that were identified in the resident's comprehensive assessment and meet professional standards of quality.

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Legacy at College Hill 5005 E 21st Street North Wichita, KS 67208

stated the previous owners had used bath sheets, and the current facility continued with the bath

bathing refusals should be charted in the resident's progress notes.

The facility ADLs policy dated

consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable.

Care and services would be provided for the following activities of daily living, bathing, dressing, grooming and oral care.

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Legacy at College Hill 5005 E 21st Street North Wichita, KS 67208

activities to support his highest psychosocial well-being when staff failed to offer and provide

the Diagnoses tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and senile degeneration of brain (progressive, age-related cognitive decline).R10's Quarterly Minimum Data Set (MDS) dated 05/15/26 documented a Brief Interview of Mental Status (BIMS) score of zero, which indicated severely impaired cognition.

The MDS documented R10 was rarely or never understood.

The MDS documented R10 was dependent on staff for all activities of daily living (ADLs).R10's Care Plan documented the following interventions:02/09/24-Stff to invite R10 to all scheduled activities.

Invite and encourage R10 to attend activities, and offer assistance for locomotion as indicated.

Staff to provide in-room activities as desired.03/28/25-R10 would be present for activities but does not always participate.05/22/25- Staff was to encourage R10 to participate in activities that promote exercise, physical activity for strengthening, and improved mobility.02/04/26-Staff to provide R10 with orientation to activities, dietary schedule a general daily schedule of the facility.Review of R10's EMR under Reports tab of the Care Records from 03/01/26-06/01/26 revealed one activity of 1:1 visit on 05/04/26.On 06/01/26 at 08:27 AM, R10 laid in his bed on his back with his eyes shut. R10's head of bed was elevated, and his bed was in a low position, with a fall mat next to his bed.On 06/01/26 at 10:40 AM, R10 laid in his bed, with his head elevated with his bed in a low position. R10's eyes were open, and his TV was on.On 06/01/26 at 12:47 PM, R10 laid in bed on his back, with his bed in a low position. R10's eyes were open, and the TV was on.On 06/02/26 at 08:34 AM, R10 laid in his bed with head of bed elevated, legs bent with his eyes open.On 06/02/26 at 12:17 PM, R10 laid on his back in his bed, his eyes were shut. R10's bed was in a low position.On 06/02/26 at 03:22 PM, R10 laid on his back in his bed. R10's eyes were open.

R10 had his TV on.On 06/03/26 at 09:52 AM, Administrative Nurse E stated R10 liked to watch TV and listen to music.

She stated there had been a lot of turnover in the last few months in the activities department.

She stated there used to be an activities person that would do activities in the memory unit.

She stated the residents like to watch TV, and when there were activities, the residents would be involved.

She stated she was aware there had not been activities in memory care in the last few days.On 06/03/26 at 01:31 PM, Administrative Nurse D stated there had been a lot of turnover in the activities department, and she was not sure how many people there had been in the last few months.

She stated she knows the facility was lacking in activities.

She stated she was aware there were no activities in the memory unit.The facility's Dementia Care policy dated 02/01/26 documented it was the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of or is diagnosed with dementia to meet his or her highest practicable physical, mental, and psychosocial well-being.

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Legacy at College Hill 5005 E 21st Street North Wichita, KS 67208

further documented R8 used a wheelchair as an assistive device.

jeopardy to resident health or Observed on 06/01/26 at 08:45 AM, staff pushed R8 in a wheelchair without foot pedals, R8's legs safety were bent at the knee, and his feet were positioned just above the floor.

On 06/01/26 at 08:45 AM, Certified Nurse Aide (CNA) QQ reported residents should not be pushed in a wheelchair without foot pedals on their wheelchairs.

She knew she had been caught pushing [R8] in his wheelchair without his foot pedals and further reported she knows she is not supposed to do that.

On 06/02/26 at 11:50 AM, Licensed Nurse (LN) I reported that staff should find the foot pedals for the wheelchair and use them any time they are pushing a resident in their wheelchair, and further reported that all residents that have wheelchairs also have foot pedals available for use on their wheelchairs.

On 06/02/26 at 01:15 PM, Administrative Nurse D reported staff were to use foot pedals when pushing a resident in their wheelchair.

The facility fall prevention policy dated 02/01/26, with date reviewed/revised 03/10/26, documents that each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.

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Legacy at College Hill 5005 E 21st Street North Wichita, KS 67208

catheter bags should be in a dignity bag.On 06/03/26 at 01:31 PM, Administrative Nurse D stated she

anchors could have gotten misplaced.

Administrative Nurse D stated R5 did not like the staff messing

mess with the catheter was the reason he did not have a dignity bag.

Administrative Nurse D stated R5 did not want a dignity bag but acknowledged that it was not in R5's plan of care.The facility's Catheter Care policy dated 02/01/26 documented It was the policy of the facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use.

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Legacy at College Hill 5005 E 21st Street North Wichita, KS 67208

06/03/26 09:39 AM, Licensed Nurse (LN)I stated she was unsure how the respiratory equipment

she would find out from her director of nursing.On 06/03/26 at 01:31 PM, Administrative Nurse D

the respiratory equipment in the bags.The facility did not provide storage of respiratory equipment as requested on 06/03/26.

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Legacy at College Hill 5005 E 21st Street North Wichita, KS 67208

any medication administration or withholding of specific medications prior to dialysis treatments; any

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Legacy at College Hill 5005 E 21st Street North Wichita, KS 67208

Findings included:- On 06/01/2026 at 07:37 AM, observation revealed that there was no nurse staffing

staffing should be posted where it could easily be viewed.

Administrative Nurse D stated that the facility did not keep documents of all daily posted nurse staffing from the last 18 months due to high turnover.The facility policy Nurse Staffing Posted Information dated 02/01/2026 documented that it was the policy of the facility to make nurse staffing information readily available in a readable format to residents, staff, and visitors at any given time.

During the process of the puree of this food item Dietary CC did not refer to the recipe for the smothered pork chops available for him to follow.On 06/02/26 at 10:35 AM, Dietary CC stated that the facility had weekly menus each month that included the recipes for each food and how they should be prepared which included the recipe for pureed foods.

Dietary CC stated he had been cooking the food and preparing the pureed food for a little while and knew what to add to thin or thicken a food when needed.On 06/02/26 at 10:36 AM, Dietary BB stated she had been the dietary manager for only two weeks and was still educating staff on proper procedures.

Dietary BB stated she would re-educate Dietary CC to ensure that he followed the recipes provided for the purees.The facility's Puree Food Preparation policy dated 02/01/26 documented that puree foods should be prepared in such a manner to prevent lumps or chunks.

The goal is a smooth, soft, homogeneous consistency similar to soft mashed potatoes. Do not use water as an additive to prepare puree foods.

Refer to your department's Dietary Services manual for additional policies and procedures.

Residents receiving puree diets should always receive portions equivalent to those served on the regular or therapeutic diet ordered per facility policy and procedure.

Puree Food Preparation Guidelines per Serving:(More or less may be used depending on the consistency of the cooked food): Meats: Add one teaspoon beef broth or beef gravy Poultry: Add one teaspoon chicken broth or chicken gravy Fish: Add one teaspoon mayonnaise Noodles: Add one teaspoon margarine Vegetables (leaf, stem, or flower): Add two teaspoon mashed potato flakes Vegetables (root, tuber): Add one teaspoon margarine Fruits (EXCEPT grapes, oranges, grapefruit, bananas, plums): Remove peels, skins, cores, pits, and or seeds.

Add one tablespoon food thickener (most watery fruits require a food thickener).

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Legacy at College Hill 5005 E 21st Street North Wichita, KS 67208