Legacy at College Hill
5005 E 21st Street North, Wichita, KS 67208 · All homes in Wichita
Legacy at College Hill, a 75-bed for profit - corporation nursing facility in Wichita, KS, holds a 1-star CMS overall rating - below the 3.0-star national average, with nurse staffing below the national norm. 6 inspection findings reached the actual-harm or immediate-jeopardy level.
CMS combines health inspections, nurse-staffing levels, and clinical quality measures into the overall star rating, read the components below; they often tell a sharper story than the headline.
Phone: 3166859291
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- 1 / 5
- Much below average · CMS overall · nat'l 3.0
- 3.86
- About average · nurse hrs/day · nat'l 3.89
- 50
- Inspection findings · 6 serious
- $96K
- Federal penalties (4)
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 175078
- Ownership
- For profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 75
- Residents
- 69
- In Hospital
- No
- County
- Sedgwick
- Last Inspection
- Feb 13, 2025
- Special Focus
- SFF Candidate
Staffing Data
How the 3.86 total nursing hours per resident-day are staffed:
- RN Hours
- 0.31 (nat'l avg: 0.68)
- LPN Hours
- 0.82
- CNA Hours
- 2.73
- Total Nursing Hours
- 3.86 (nat'l avg: 3.89)
- PT Hours
- 0.01
- Nursing Turnover
- 47.9%
What the CMS Record Reveals About Legacy at College Hill
Legacy at College Hill operates 75 certified beds in Wichita, KS with approximately 69 residents currently in care, and carries a CMS overall rating of 1 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (3★), and quality measures (3★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone, a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 50 deficiency records from recent surveys, of which 6 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 4 penalties totaling $96K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.86 total nursing hours per resident day (national average 3.89), with RN coverage at 0.31 per resident day, the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature. This facility is currently designated "SFF Candidate" under the CMS Special Focus Facility program, reserved for providers with a persistent pattern of serious quality problems.
Classified as "For profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, Legacy at College Hill falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes, ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 47.9%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report, the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (50 most recent)
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Category: Environmental Deficiencies
Corrected: Jun 20, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 20, 2025
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.
Category: Resident Rights Deficiencies
Corrected: Jun 20, 2025
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Category: Environmental Deficiencies
Corrected: Mar 7, 2025
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Mar 7, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Mar 7, 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.
Category: Administration Deficiencies
Corrected: Mar 7, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Mar 7, 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.
Category: Pharmacy Service Deficiencies
Corrected: Mar 7, 2025
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.
Category: Pharmacy Service Deficiencies
Corrected: Mar 7, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category: Pharmacy Service Deficiencies
Corrected: Mar 7, 2025
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Mar 7, 2025
Provide care or services that was trauma informed and/or culturally competent.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 7, 2025
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 7, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 7, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Mar 7, 2025
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.
Category: Resident Rights Deficiencies
Corrected: Mar 7, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Aug 23, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Aug 23, 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.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 23, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 23, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 23, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Aug 23, 2024
Make sure that a working call system is available in each resident's bathroom and bathing area.
Category: Environmental Deficiencies
Corrected: Jun 15, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jun 15, 2023
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Category: Administration Deficiencies
Corrected: Jun 15, 2023
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Category: Administration Deficiencies
Corrected: Jun 15, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Jun 15, 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.
Category: Pharmacy Service Deficiencies
Corrected: Jun 15, 2023
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Jun 15, 2023
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Jun 15, 2023
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 15, 2023
Observe each nurse aide's job performance and give regular training.
Category: Nursing and Physician Services Deficiencies
Corrected: Jun 15, 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.
Category: Nursing and Physician Services Deficiencies
Corrected: Jun 15, 2023
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category: Nursing and Physician Services Deficiencies
Corrected: Jun 15, 2023
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Category: Nursing and Physician Services Deficiencies
Corrected: Jun 15, 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.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 15, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 15, 2023
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 15, 2023
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 15, 2023
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 15, 2023
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 15, 2023
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 15, 2023
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 15, 2023
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 15, 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.
Category: Resident Rights Deficiencies
Corrected: Jun 15, 2023
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Jun 15, 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.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 15, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 5, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Nov 8, 2021
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 15.6% | Yes |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 1.5% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 1.6% | Yes |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 4.1% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 7.8% | Yes |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 6.7% | Yes |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 22.1% | Yes |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.0% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 10.4% | No |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 4.0% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 91.0% | No |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 20.4% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 98.6% | No |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 10.7% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 81.6% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | N/A | No |
Penalty History 4 penalties totaling $96K
| Date | Type | Amount |
|---|---|---|
| Mar 12, 2025 | Fine | $8K |
| Mar 12, 2025 | Payment Denial | - |
| Jul 30, 2024 | Fine | $35K |
| May 2, 2023 | Fine | $44K |
| May 2, 2023 | Payment Denial | - |
| Apr 10, 2023 | Fine | $9K |
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Understanding Nursing Home Data
Frequently Asked Questions
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Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology - how this data is sourced, computed, and verified.
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