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Legacy At College Hill

📍 5005 E 21st Street North, Wichita, KS 67208 📞 (316) 685-9291 🛏️ 85 beds

Inspection History Overview

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

$12,740
Mar 12, 2025

Fine

$0
Mar 12, 2025

Payment Denial

2021 3 penalties totaling $69,153

$41,419
Oct 5, 2021

Fine

$27,079
Jul 22, 2021

Fine

$655
Jun 21, 2021

Fine

2020 1 penalties totaling $6,923

$6,923
Sep 28, 2020

Fine

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Health Violations by Year

2025 12 violations

Tag 0657 D Feb 13, 2025

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

✓ Corrected: Mar 7, 2025
Tag 0689 D Feb 13, 2025

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

✓ Corrected: Mar 7, 2025
Tag 0698 D Feb 13, 2025

Provide safe, appropriate dialysis care/services for a resident who requires such services.

✓ Corrected: Mar 7, 2025
Tag 0699 D Feb 13, 2025

Provide care or services that was trauma informed and/or culturally competent.

✓ Corrected: Mar 7, 2025
Tag 0756 D Feb 13, 2025

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

✓ Corrected: Mar 7, 2025
Tag 0757 D Feb 13, 2025

Ensure each resident’s drug regimen must be free from unnecessary drugs.

✓ Corrected: Mar 7, 2025
Tag 0761 D Feb 13, 2025

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.

✓ Corrected: Mar 7, 2025
Tag 0812 E Feb 13, 2025

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

✓ Corrected: Mar 7, 2025
Tag 0849 D Feb 13, 2025

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.

✓ Corrected: Mar 7, 2025
Tag 0880 F Feb 13, 2025

Provide and implement an infection prevention and control program.

✓ Corrected: Mar 7, 2025
Tag 0883 E Feb 13, 2025

Develop and implement policies and procedures for flu and pneumonia vaccinations.

✓ Corrected: Mar 7, 2025
Tag 0921 F Feb 13, 2025

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

✓ Corrected: Mar 7, 2025

2024 6 violations

Tag 0657 D Jul 30, 2024

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Tag 0684 D Jul 30, 2024

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Tag 0686 G Jul 30, 2024

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Tag 0690 D Jul 30, 2024

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Tag 0755 D Jul 30, 2024

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Tag 0880 D Jul 30, 2024

Provide and implement an infection prevention and control program.

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2023 26 violations

Tag 0550 D May 2, 2023

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

✓ Corrected: Jun 15, 2023
Tag 0584 F May 2, 2023

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.

✓ Corrected: Jun 15, 2023
Tag 0600 L May 2, 2023

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

✓ Corrected: Jun 15, 2023
Tag 0609 K May 2, 2023

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

✓ Corrected: Jun 15, 2023
Tag 0610 L May 2, 2023

Respond appropriately to all alleged violations.

✓ Corrected: Jun 15, 2023
Tag 0644 D May 2, 2023

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

✓ Corrected: Jun 15, 2023
Tag 0646 D May 2, 2023

Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.

✓ Corrected: Jun 15, 2023
Tag 0656 D May 2, 2023

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

✓ Corrected: Jun 15, 2023
Tag 0676 D May 2, 2023

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

✓ Corrected: Jun 15, 2023
Tag 0689 G May 2, 2023

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

✓ Corrected: Jun 15, 2023
Tag 0690 D May 2, 2023

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

✓ Corrected: Jun 15, 2023
Tag 0700 E May 2, 2023

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.

✓ Corrected: Jun 15, 2023
Tag 0712 D May 2, 2023

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

✓ Corrected: Jun 15, 2023
Tag 0725 F May 2, 2023

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

✓ Corrected: Jun 15, 2023
Tag 0727 F May 2, 2023

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.

✓ Corrected: Jun 15, 2023
Tag 0730 D May 2, 2023

Observe each nurse aide's job performance and give regular training.

✓ Corrected: Jun 15, 2023
Tag 0741 E May 2, 2023

Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.

✓ Corrected: Jun 15, 2023
Tag 0755 D May 2, 2023

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

✓ Corrected: Jun 15, 2023
Tag 0756 E May 2, 2023

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

✓ Corrected: Jun 15, 2023
Tag 0758 E May 2, 2023

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.

✓ Corrected: Jun 15, 2023

2021 28 violations

Tag 0550 D Oct 5, 2021

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

✓ Corrected: Nov 8, 2021
Tag 0574 D Oct 5, 2021

The resident has the right to receive notices in a format and a language he or she understands.

✓ Corrected: Nov 8, 2021
Tag 0623 D Oct 5, 2021

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

✓ Corrected: Nov 8, 2021
Tag 0625 D Oct 5, 2021

Notify 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.

✓ Corrected: Nov 8, 2021
Tag 0656 D Oct 5, 2021

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

✓ Corrected: Nov 8, 2021
Tag 0657 D Oct 5, 2021

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

✓ Corrected: Nov 8, 2021
Tag 0677 D Oct 5, 2021

Provide care and assistance to perform activities of daily living for any resident who is unable.

✓ Corrected: Nov 8, 2021
Tag 0686 G Oct 5, 2021

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

✓ Corrected: Nov 8, 2021
Tag 0690 D Oct 5, 2021

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

✓ Corrected: Nov 8, 2021
Tag 0692 G Oct 5, 2021

Provide enough food/fluids to maintain a resident's health.

✓ Corrected: Nov 8, 2021
Tag 0695 D Oct 5, 2021

Provide safe and appropriate respiratory care for a resident when needed.

✓ Corrected: Nov 8, 2021
Tag 0727 F Oct 5, 2021

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.

✓ Corrected: Nov 8, 2021
Tag 0756 D Oct 5, 2021

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

✓ Corrected: Nov 8, 2021
Tag 0757 D Oct 5, 2021

Ensure each resident’s drug regimen must be free from unnecessary drugs.

✓ Corrected: Nov 8, 2021
Tag 0758 D Oct 5, 2021

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.

✓ Corrected: Nov 8, 2021
Tag 0761 D Oct 5, 2021

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.

✓ Corrected: Nov 8, 2021
Tag 0801 F Oct 5, 2021

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.

✓ Corrected: Nov 8, 2021
Tag 0812 F Oct 5, 2021

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

✓ Corrected: Nov 8, 2021
Tag 0838 F Oct 5, 2021

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.

✓ Corrected: Nov 8, 2021
Tag 0867 F Oct 5, 2021

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

✓ Corrected: Nov 8, 2021
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2020 1 violations

Tag 0689 J Sep 28, 2020

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

✓ Corrected: Sep 2, 2020

2019 6 violations

Tag 0577 C Dec 16, 2019

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

✓ Corrected: Jan 14, 2020
Tag 0623 D Dec 16, 2019

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

✓ Corrected: Jan 14, 2020
Tag 0657 D Dec 16, 2019

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

✓ Corrected: Jan 14, 2020
Tag 0688 D Dec 16, 2019

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.

✓ Corrected: Jan 14, 2020
Tag 0756 D Dec 16, 2019

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

✓ Corrected: Jan 14, 2020
Tag 0757 D Dec 16, 2019

Ensure each resident’s drug regimen must be free from unnecessary drugs.

✓ Corrected: Jan 14, 2020
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2017 14 violations

Tag 0156 D Sep 20, 2017

Give residents a notice of rights, rules, services and charges.

✓ Corrected: Oct 20, 2017
Tag 0170 F Sep 20, 2017

Send unopened mail from residents and promptly deliver unopened mail to residents.

✓ Corrected: Oct 20, 2017
Tag 0242 D Sep 20, 2017

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.

✓ Corrected: Oct 20, 2017
Tag 0312 D Sep 20, 2017

Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.

✓ Corrected: Oct 20, 2017
Tag 0314 D Sep 20, 2017

Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.

✓ Corrected: Oct 20, 2017
Tag 0323 D Sep 20, 2017

Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

✓ Corrected: Oct 20, 2017
Tag 0362 E Sep 20, 2017

Hire sufficient dietary support personnel.

✓ Corrected: Oct 20, 2017
Tag 0364 E Sep 20, 2017

Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.

✓ Corrected: Oct 20, 2017
Tag 0371 E Sep 20, 2017

Store, cook, and serve food in a safe and clean way.

✓ Corrected: Oct 20, 2017
Tag 0431 E Sep 20, 2017

Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.

✓ Corrected: Oct 20, 2017
Tag 0441 F Sep 20, 2017

Have a program that investigates, controls and keeps infection from spreading.

✓ Corrected: Oct 20, 2017
Tag 0280 D Jul 6, 2017

Allow residents the right to participate in the planning or revision of care and treatment.

✓ Corrected: Jul 31, 2017
Tag 0323 J Jul 6, 2017

Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

✓ Corrected: Jul 6, 2017
Tag 0354 F Jul 6, 2017

Use a registered nurse at least 8 hours a day, 7 days a week.

✓ Corrected: Jul 31, 2017
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