Facility WatchInspection records for every certified US nursing home
Legacy at College Hill
5005 E 21st Street North Wichita, KS 67208 (316) 685-9291
Special Focus Facility — SFF Candidate
CCN
175078
Certified beds
75
Ownership
For profit - Corporation
Chain
Campbell Street Services
Nurse staffing
4.38
Total nurse staffing hours per resident per day, case-mix adjusted
Registered nurses: 0.41 hours per resident per day
Nursing staff turnover: 51% a year
Derived by CMS from the Payroll-Based Journal and refreshed quarterly.
Inspection history
Inspected May 21, 2025
3 citations · from a complaint investigation · Health
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected June 20, 2025
E
F0584No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected June 20, 2025
F
F0925No actual harm with potential for more than minimal harm · Widespread
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Deficient, Provider has date of correction · corrected June 20, 2025
Inspected February 13, 2025
14 citations · from a complaint investigation · Health
D
F0625No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected March 7, 2025
D
F0657No actual harm with potential for more than minimal harm · Isolated
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Deficient, Provider has date of correction · corrected March 7, 2025
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected March 7, 2025
D
F0698No actual harm with potential for more than minimal harm · Isolated
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Deficient, Provider has date of correction · corrected March 7, 2025
D
F0699No actual harm with potential for more than minimal harm · Isolated
Provide care or services that was trauma informed and/or culturally competent.
Deficient, Provider has date of correction · corrected March 7, 2025
D
F0756No actual harm with potential for more than minimal harm · Isolated
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Deficient, Provider has date of correction · corrected March 7, 2025
D
F0757No actual harm with potential for more than minimal harm · Isolated
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Deficient, Provider has date of correction · corrected March 7, 2025
D
F0758No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected March 7, 2025
D
F0761No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected March 7, 2025
D
F0849No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected March 7, 2025
E
F0812No actual harm with potential for more than minimal harm · Pattern
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected March 7, 2025
E
F0883No actual harm with potential for more than minimal harm · Pattern
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Deficient, Provider has date of correction · corrected March 7, 2025
F
F0880No actual harm with potential for more than minimal harm · Widespread
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected March 7, 2025
F
F0921No actual harm with potential for more than minimal harm · Widespread
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Deficient, Provider has date of correction · corrected March 7, 2025
Inspected July 30, 2024
6 citations · from a complaint investigation · Health
D
F0657No actual harm with potential for more than minimal harm · Isolated
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Deficient, Provider has date of correction · corrected August 23, 2024
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected August 23, 2024
D
F0690No actual harm with potential for more than minimal harm · Isolated
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Deficient, Provider has date of correction · corrected August 23, 2024
D
F0755No actual harm with potential for more than minimal harm · Isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected August 23, 2024
D
F0880No actual harm with potential for more than minimal harm · Isolated
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected August 23, 2024
G
F0686Actual harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected August 23, 2024
Inspected May 2, 2023
25 citations · Health
D
F0550No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected June 15, 2023
D
F0644No actual harm with potential for more than minimal harm · Isolated
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Deficient, Provider has date of correction · corrected June 15, 2023
D
F0646No actual harm with potential for more than minimal harm · Isolated
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Deficient, Provider has date of correction · corrected June 15, 2023
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected June 15, 2023
D
F0676No actual harm with potential for more than minimal harm · Isolated
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Deficient, Provider has date of correction · corrected June 15, 2023
D
F0690No actual harm with potential for more than minimal harm · Isolated
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Deficient, Provider has date of correction · corrected June 15, 2023
D
F0712No actual harm with potential for more than minimal harm · Isolated
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Deficient, Provider has date of correction · corrected June 15, 2023
D
F0730No actual harm with potential for more than minimal harm · Isolated
Observe each nurse aide's job performance and give regular training.
Deficient, Provider has date of correction · corrected June 15, 2023
D
F0755No actual harm with potential for more than minimal harm · Isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected June 15, 2023
E
F0700No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected June 15, 2023
E
F0741No actual harm with potential for more than minimal harm · Pattern
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Deficient, Provider has date of correction · corrected June 15, 2023
E
F0756No actual harm with potential for more than minimal harm · Pattern
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Deficient, Provider has date of correction · corrected June 15, 2023
E
F0758No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected June 15, 2023
F
F0584No actual harm with potential for more than minimal harm · Widespread
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.
Deficient, Provider has date of correction · corrected June 15, 2023
F
F0725No actual harm with potential for more than minimal harm · Widespread
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Deficient, Provider has date of correction · corrected June 15, 2023
F
F0727No actual harm with potential for more than minimal harm · Widespread
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.
Deficient, Provider has date of correction · corrected June 15, 2023
F
F0812No actual harm with potential for more than minimal harm · Widespread
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected June 15, 2023
F
F0835No actual harm with potential for more than minimal harm · Widespread
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Deficient, Provider has date of correction · corrected June 15, 2023
F
F0868No actual harm with potential for more than minimal harm · Widespread
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Deficient, Provider has date of correction · corrected June 15, 2023
F
F0880No actual harm with potential for more than minimal harm · Widespread
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected June 15, 2023
F
F0919No actual harm with potential for more than minimal harm · Widespread
Make sure that a working call system is available in each resident's bathroom and bathing area.
Deficient, Provider has date of correction · corrected June 15, 2023
G
F0689Actual harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected June 15, 2023
K
F0609Immediate jeopardy to resident health or safety · Pattern
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected June 15, 2023
L
F0600Immediate jeopardy to resident health or safety · Widespread
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected June 15, 2023
L
F0610Immediate jeopardy to resident health or safety · Widespread
Respond appropriately to all alleged violations.
Deficient, Provider has date of correction · corrected June 15, 2023
Inspected October 5, 2021
22 citations · Health
D
F0550No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected November 8, 2021
D
F0574No actual harm with potential for more than minimal harm · Isolated
The resident has the right to receive notices in a format and a language he or she understands.
Deficient, Provider has date of correction · corrected November 8, 2021
D
F0623No actual harm with potential for more than minimal harm · Isolated
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Deficient, Provider has date of correction · corrected November 8, 2021
D
F0625No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected November 8, 2021
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected November 8, 2021
D
F0657No actual harm with potential for more than minimal harm · Isolated
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Deficient, Provider has date of correction · corrected November 8, 2021
D
F0677No actual harm with potential for more than minimal harm · Isolated
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected November 8, 2021
D
F0690No actual harm with potential for more than minimal harm · Isolated
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Deficient, Provider has date of correction · corrected November 8, 2021
D
F0695No actual harm with potential for more than minimal harm · Isolated
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected November 8, 2021
D
F0756No actual harm with potential for more than minimal harm · Isolated
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Deficient, Provider has date of correction · corrected November 8, 2021
D
F0757No actual harm with potential for more than minimal harm · Isolated
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Deficient, Provider has date of correction · corrected November 8, 2021
D
F0758No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected November 8, 2021
D
F0761No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected November 8, 2021
D
F0880No actual harm with potential for more than minimal harm · Isolated
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected November 8, 2021
F
F0727No actual harm with potential for more than minimal harm · Widespread
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.
Deficient, Provider has date of correction · corrected November 8, 2021
F
F0801No actual harm with potential for more than minimal harm · Widespread
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.
Deficient, Provider has date of correction · corrected November 8, 2021
F
F0812No actual harm with potential for more than minimal harm · Widespread
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected November 8, 2021
F
F0838No actual harm with potential for more than minimal harm · Widespread
Conduct 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.
Deficient, Provider has date of correction · corrected November 8, 2021
F
F0867No actual harm with potential for more than minimal harm · Widespread
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Deficient, Provider has date of correction · corrected November 8, 2021
F
F0868No actual harm with potential for more than minimal harm · Widespread
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Deficient, Provider has date of correction · corrected November 8, 2021
G
F0686Actual harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected November 8, 2021
G
F0692Actual harm · Isolated
Provide enough food/fluids to maintain a resident's health.
Deficient, Provider has date of correction · corrected November 8, 2021