Starfile / Kansas

LEGACY AT COLLEGE HILL

5005 E 21ST STREET NORTH, WICHITA, KS 67208 · CCN 175078

SFF Candidate

Inspection history vs Kansas & national averages

Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.

Cycle 1 deficiencies by category

Staffing (hours per resident per day)

Fines & penalties

Total fines

$96,031

Number of fines

4

Number of penalties

6

Payment denials

2

Chain

Chain

CAMPBELL STREET SERVICES

Facilities in chain

16

Chain avg overall

2.10 / 5

Inspection citations (71)4 immediate jeopardy4 actual harm

1. EF0584Honor 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.2025-05-21 · Health · corrected 2025-06-20

   Potential for more than minimal harm

2. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-05-21 · Health · corrected 2025-06-20

   Potential for more than minimal harm

3. FF0925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.2025-05-21 · Health · corrected 2025-06-20

   Potential for more than minimal harm

4. DF0625Notify 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.2025-02-13 · Health · corrected 2025-03-07

   Potential for more than minimal harm

5. DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2025-02-13 · Health · corrected 2025-03-07

   Potential for more than minimal harm

6. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-02-13 · Health · corrected 2025-03-07

   Potential for more than minimal harm

7. DF0698Provide safe, appropriate dialysis care/services for a resident who requires such services.2025-02-13 · Health · corrected 2025-03-07

   Potential for more than minimal harm

8. DF0699Provide care or services that was trauma informed and/or culturally competent.2025-02-13 · Health · corrected 2025-03-07

   Potential for more than minimal harm

9. DF0756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.2025-02-13 · Health · corrected 2025-03-07

   Potential for more than minimal harm

10. DF0757Ensure each resident’s drug regimen must be free from unnecessary drugs.2025-02-13 · Health · corrected 2025-03-07

    Potential for more than minimal harm

11. DF0758Implement 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.2025-02-13 · Health · corrected 2025-03-07

    Potential for more than minimal harm

12. DF0761Ensure 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.2025-02-13 · Health · corrected 2025-03-07

    Potential for more than minimal harm

13. EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2025-02-13 · Health · corrected 2025-03-07

    Potential for more than minimal harm

14. DF0849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.2025-02-13 · Health · corrected 2025-03-07

    Potential for more than minimal harm

15. FF0880Provide and implement an infection prevention and control program.2025-02-13 · Health · corrected 2025-03-07

    Potential for more than minimal harm

16. EF0883Develop and implement policies and procedures for flu and pneumonia vaccinations.2025-02-13 · Health · corrected 2025-03-07

    Potential for more than minimal harm

17. FF0921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.2025-02-13 · Health · corrected 2025-03-07

    Potential for more than minimal harm

18. DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2024-07-30 · Health · corrected 2024-08-23

    Potential for more than minimal harm

19. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2024-07-30 · Health · corrected 2024-08-23

    Potential for more than minimal harm

20. GF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2024-07-30 · Health · corrected 2024-08-23

    Actual harm

21. DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2024-07-30 · Health · corrected 2024-08-23

    Potential for more than minimal harm

22. DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2024-07-30 · Health · corrected 2024-08-23

    Potential for more than minimal harm

23. DF0880Provide and implement an infection prevention and control program.2024-07-30 · Health · corrected 2024-08-23

    Potential for more than minimal harm

24. DF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2023-05-02 · Health · corrected 2023-06-15

    Potential for more than minimal harm

25. FF0584Honor 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.2023-05-02 · Health · corrected 2023-06-15

    Potential for more than minimal harm

26. LF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2023-05-02 · Health · corrected 2023-06-15

    Immediate jeopardy

27. KF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2023-05-02 · Health · corrected 2023-06-15

    Immediate jeopardy

28. LF0610Respond appropriately to all alleged violations.2023-05-02 · Health · corrected 2023-06-15

    Immediate jeopardy

29. DF0644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.2023-05-02 · Health · corrected 2023-06-15

    Potential for more than minimal harm

30. DF0646Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.2023-05-02 · Health · corrected 2023-06-15

    Potential for more than minimal harm

31. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2023-05-02 · Health · corrected 2023-06-15

    Potential for more than minimal harm

32. DF0676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.2023-05-02 · Health · corrected 2023-06-15

    Potential for more than minimal harm

33. GF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-05-02 · Health · corrected 2023-06-15

    Actual harm

34. DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2023-05-02 · Health · corrected 2023-06-15

    Potential for more than minimal harm

35. EF0700Try 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.2023-05-02 · Health · corrected 2023-06-15

    Potential for more than minimal harm

36. DF0712Ensure that the resident and his/her doctor meet face-to-face at all required visits.2023-05-02 · Health · corrected 2023-06-15

    Potential for more than minimal harm

37. FF0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.2023-05-02 · Health · corrected 2023-06-15

    Potential for more than minimal harm

38. FF0727Have 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.2023-05-02 · Health · corrected 2023-06-15

    Potential for more than minimal harm

39. DF0730Observe each nurse aide's job performance and give regular training.2023-05-02 · Health · corrected 2023-06-15

    Potential for more than minimal harm

40. EF0741Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.2023-05-02 · Health · corrected 2023-06-15

    Potential for more than minimal harm

41. DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2023-05-02 · Health · corrected 2023-06-15

    Potential for more than minimal harm

42. EF0756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.2023-05-02 · Health · corrected 2023-06-15

    Potential for more than minimal harm

43. EF0758Implement 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.2023-05-02 · Health · corrected 2023-06-15

    Potential for more than minimal harm

44. FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2023-05-02 · Health · corrected 2023-06-15

    Potential for more than minimal harm

45. FF0835Administer the facility in a manner that enables it to use its resources effectively and efficiently.2023-05-02 · Health · corrected 2023-06-15

    Potential for more than minimal harm

46. FF0868Have the Quality Assessment and Assurance group have the required members and meet at least quarterly2023-05-02 · Health · corrected 2023-06-15

    Potential for more than minimal harm

47. FF0880Provide and implement an infection prevention and control program.2023-05-02 · Health · corrected 2023-06-15

    Potential for more than minimal harm

48. FF0919Make sure that a working call system is available in each resident's bathroom and bathing area.2023-05-02 · Health · corrected 2023-06-15

    Potential for more than minimal harm

49. JF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-04-10 · Health · corrected 2023-04-05

    Immediate jeopardy

50. DF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2021-10-05 · Health · corrected 2021-11-08

    Potential for more than minimal harm

51. DF0574The resident has the right to receive notices in a format and a language he or she understands.2021-10-05 · Health · corrected 2021-11-08

    Potential for more than minimal harm

52. DF0623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.2021-10-05 · Health · corrected 2021-11-08

    Potential for more than minimal harm

53. DF0625Notify 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.2021-10-05 · Health · corrected 2021-11-08

    Potential for more than minimal harm

54. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2021-10-05 · Health · corrected 2021-11-08

    Potential for more than minimal harm

55. DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2021-10-05 · Health · corrected 2021-11-08

    Potential for more than minimal harm

56. DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2021-10-05 · Health · corrected 2021-11-08

    Potential for more than minimal harm

57. GF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2021-10-05 · Health · corrected 2021-11-08

    Actual harm

58. DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2021-10-05 · Health · corrected 2021-11-08

    Potential for more than minimal harm

59. GF0692Provide enough food/fluids to maintain a resident's health.2021-10-05 · Health · corrected 2021-11-08

    Actual harm

60. DF0695Provide safe and appropriate respiratory care for a resident when needed.2021-10-05 · Health · corrected 2021-11-08

    Potential for more than minimal harm

61. FF0727Have 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.2021-10-05 · Health · corrected 2021-11-08

    Potential for more than minimal harm

62. DF0756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.2021-10-05 · Health · corrected 2021-11-08

    Potential for more than minimal harm

63. DF0757Ensure each resident’s drug regimen must be free from unnecessary drugs.2021-10-05 · Health · corrected 2021-11-08

    Potential for more than minimal harm

64. DF0758Implement 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.2021-10-05 · Health · corrected 2021-11-08

    Potential for more than minimal harm

65. DF0761Ensure 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.2021-10-05 · Health · corrected 2021-11-08

    Potential for more than minimal harm

66. FF0801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.2021-10-05 · Health · corrected 2021-11-08

    Potential for more than minimal harm

67. FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2021-10-05 · Health · corrected 2021-11-08

    Potential for more than minimal harm

68. FF0838Conduct 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.2021-10-05 · Health · corrected 2021-11-08

    Potential for more than minimal harm

69. FF0867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.2021-10-05 · Health · corrected 2021-11-08

    Potential for more than minimal harm

70. FF0868Have the Quality Assessment and Assurance group have the required members and meet at least quarterly2021-10-05 · Health · corrected 2021-11-08

    Potential for more than minimal harm

71. DF0880Provide and implement an infection prevention and control program.2021-10-05 · Health · corrected 2021-11-08

    Potential for more than minimal harm

Ownership

Other facilities in WICHITA

Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.