Federal Nursing-Home Survey Record
LEGACY AT COLLEGE HILL
Does LEGACY AT COLLEGE HILL have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), LEGACY AT COLLEGE HILL (CCN 175078), in WICHITA, KS, has federal inspection findings on its record. CMS also lists the facility as a candidate for its Special Focus Facility program; a candidate is not on the active watch list. In its current inspection cycle, CMS cited the facility for 17 deficiencies; the most serious carries scope/severity F on CMS's A–L scale. The most recent federal survey on file is dated 2025-02-13. Citations from earlier inspection cycles appear in the dated timeline below as historical findings, not current ones. CMS has $43,188 in civil money penalties on file against the facility. This page restates the federal record as published by CMS and draws no conclusion of its own. Strict time limits can apply to claims like these — consider consulting a qualified attorney promptly.
The Federal Record
CMS has $43,188 in civil money penalties on file against this facility.
Below is this facility's federal survey record as on file with federal regulators (CMS). Strict time limits can apply to claims like these — consider consulting a qualified attorney promptly.
A candidate for the federal Special Focus Facility watch list
CMS lists this facility as a candidate for the Special Focus Facility program. It is not on the active watch list.
Scope & Severity — current cycle
Civil money penalties on file
$43,188
CMS has $43,188 in civil money penalties on file against this facility. CMS also records 10 day(s) of payment denial.
Overall CMS star rating: this facility vs the CMS-published state average
This facility: 1 · CMS state average: 3.0
Deficiency timeline — full federal history
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Provide and implement an infection prevention and control program.
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide care or services that was trauma informed and/or culturally competent.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
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.
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.
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.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide and implement an infection prevention and control program.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Respond appropriately to all alleged violations.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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.
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Provide and implement an infection prevention and control program.
Make sure that a working call system is available in each resident's bathroom and bathing area.
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.
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
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.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Observe each nurse aide's job performance and give regular training.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide enough food/fluids to maintain a resident's health.
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.
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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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.
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Document what happened
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Strict time limits can apply to claims like these — consider consulting a qualified attorney promptly.