Public Record
Legacy at Herington
Operated by Campbell Street Services
From CMS
Facility profile
- CMS overall rating
- 1 / 5
- Certified beds
- 45
- Avg. residents per day
- 26.9
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Health citations
- 45
- Fire safety findings
- 54
- Inspections on file
- 10
- Last inspection
- 2025-03-28
*CMS
*CMS
*CMS
*CMS
Citations
45 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0851Generalpotential for harm
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0804Generalpotential for harm
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- 0801Generalpotential for harm
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.
- 0761Generalpotential for harm
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.
- 0758Generalpotential for harm
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.
- 0757Generalpotential for harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- 0756Generalpotential for harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- 0732Generalno actual harm
Post nurse staffing information every day.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0623Generalpotential for harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0697Generalpotential for harm
Provide safe, appropriate pain management for a resident who requires such services.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0563Generalpotential for harm
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
- 0564Generalpotential for harm
Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.
- 0600Generalpotential for harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0600Seriousimmediate jeopardy
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- 0623Generalpotential for harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0686Generalpotential for harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0688Generalpotential for harm
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.
- 0689Seriousimmediate jeopardy
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0690Generalpotential for harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0692Generalpotential for harm
Provide enough food/fluids to maintain a resident's health.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0756Generalpotential for harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- 0757Generalpotential for harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- 0779Generalpotential for harm
Keep signed and dated reports of x-rays and other diagnostic services in the residents record.
- 0801Generalpotential for harm
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.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0835Generalpotential for harm
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
- 0867Generalpotential for harm
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
- 0868Generalpotential for harm
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0881Generalpotential for harm
Implement a program that monitors antibiotic use.
- 0883Generalpotential for harm
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- 0887Generalpotential for harm
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
- 0583Generalpotential for harm
Keep residents' personal and medical records private and confidential.
- 0582Generalpotential for harm
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
Inspection history
Every health inspection on record
Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.
- View inspection reportInspectionFire Safety2 deficiencies
- View inspection reportInspectionFire Safety20 deficiencies
- View inspection reportInspection14 deficiencies
- View inspection reportInspection3 deficiencies
- View inspection reportInspection2 deficiencies
- View inspection reportInspectionFire Safety17 deficiencies
- View inspection reportInspection22 deficiencies
- View inspection reportInspection1 deficiency
- View inspection reportInspection3 deficiencies
- View inspection reportInspectionFire Safety15 deficiencies
Ownership
Campbell Street Services
20nursing homes nationwide, in CMS records
FAQ
Questions and answers
- What is Legacy at Herington?
- Legacy at Herington is a Medicare- and Medicaid-certified nursing home in Herington, KS, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 175490.
- What is the CMS rating for Legacy at Herington?
- Legacy at Herington has a CMS overall rating of 1 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Legacy at Herington have?
- Legacy at Herington is certified for 45 beds. It serves an average of 26.9 residents per day.
- How many citations does Legacy at Herington have?
- Legacy at Herington has 45 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Legacy at Herington last inspected?
- Legacy at Herington was last inspected on March 28, 2025. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
/nursing-home/175490-legacy-at-herington