LEGACY AT COLLEGE HILL

πŸ“ 5005 E 21ST STREET NORTH, wichita, KS 67208 πŸ“ž 3166859291 πŸ›οΈ 85 beds

Overall Rating

⭐⭐⭐⭐
4/5

Health Inspection

⭐⭐⭐⭐
4/5

Staffing

⭐⭐
2/5

Quality Measures

⭐⭐⭐⭐
4/5

Inspection History Overview

93
Total Violations
7 years of data
$88,816
Total Fines
6 penalties
6
Inspections
Since 2014
21
Quality Metrics
Tracked measures

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.

βœ“ 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.

βœ“ Corrected: Mar 7, 2025
Tag 0698 D Feb 13, 2025

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

βœ“ Corrected: Mar 7, 2025
Tag 0699 D Feb 13, 2025

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

βœ“ 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.

βœ“ Corrected: Mar 7, 2025
Tag 0757 D Feb 13, 2025

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

βœ“ 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.

βœ“ 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.

βœ“ 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.

βœ“ Corrected: Mar 7, 2025
Tag 0880 F Feb 13, 2025

Provide and implement an infection prevention and control program.

βœ“ Corrected: Mar 7, 2025
Tag 0883 E Feb 13, 2025

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

βœ“ 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.

βœ“ 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.

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.

βœ“ 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.

βœ“ 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.

βœ“ 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.

βœ“ Corrected: Jun 15, 2023
Tag 0610 L May 2, 2023

Respond appropriately to all alleged violations.

βœ“ 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.

βœ“ 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.

βœ“ 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.

βœ“ 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.

βœ“ 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.

βœ“ 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.

βœ“ 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.

βœ“ 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.

βœ“ 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.

βœ“ 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.

βœ“ Corrected: Jun 15, 2023
Tag 0730 D May 2, 2023

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

βœ“ 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.

βœ“ 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.

βœ“ 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.

βœ“ 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.

βœ“ 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.

βœ“ 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.

βœ“ 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.

βœ“ 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.

βœ“ 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.

βœ“ 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.

βœ“ 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.

βœ“ Corrected: Nov 8, 2021
Tag 0686 G Oct 5, 2021

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

βœ“ 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.

βœ“ Corrected: Nov 8, 2021
Tag 0692 G Oct 5, 2021

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

βœ“ Corrected: Nov 8, 2021
Tag 0695 D Oct 5, 2021

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

βœ“ 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.

βœ“ 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.

βœ“ Corrected: Nov 8, 2021
Tag 0757 D Oct 5, 2021

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

βœ“ 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.

βœ“ 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.

βœ“ 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.

βœ“ 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.

βœ“ 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.

βœ“ 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.

βœ“ Corrected: Nov 8, 2021

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.

βœ“ 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.

βœ“ 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.

βœ“ 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.

βœ“ 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.

βœ“ 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.

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

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

βœ“ Corrected: Jan 14, 2020

2017 14 violations

Tag 0156 D Sep 20, 2017

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

βœ“ Corrected: Oct 20, 2017
Tag 0170 F Sep 20, 2017

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

βœ“ 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.

βœ“ 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.

βœ“ 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.

βœ“ 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.

βœ“ Corrected: Oct 20, 2017
Tag 0362 E Sep 20, 2017

Hire sufficient dietary support personnel.

βœ“ 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.

βœ“ Corrected: Oct 20, 2017
Tag 0371 E Sep 20, 2017

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

βœ“ 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.

βœ“ Corrected: Oct 20, 2017
Tag 0441 F Sep 20, 2017

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

βœ“ 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.

βœ“ 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.

βœ“ Corrected: Jul 6, 2017
Tag 0354 F Jul 6, 2017

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

βœ“ Corrected: Jul 31, 2017

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
Fine
March 12, 2025
$0
Payment Denial
March 12, 2025
Average: $6,370 | Range: $0 - $12,740

2021 3 penalties totaling $69,153

$41,419
Fine
October 5, 2021
$27,079
Fine
July 22, 2021
$655
Fine
June 21, 2021
Average: $23,051 | Range: $655 - $41,419

2020 1 penalties totaling $6,923

$6,923
Fine
September 28, 2020
Average: $6,923 | Range: $6,923 - $6,923

Fire Safety Deficiencies

Unknown Date

No description available

Inspection Survey Reports

Health

July 30, 2024
0.00

Health

May 2, 2023
0.00

Health

April 10, 2023
0.00

Health

October 5, 2021
0.00

Health

July 22, 2021
0.00

Health

December 16, 2019
0.00

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Ownership Information

For profit - Individual
Independent (Not part of a chain)
175078
175078
3166859291
Sedgwick

Historical Ownership Records

August 25, 2025
Organization
August 25, 2025
Organization
August 25, 2025
Organization