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Legacy At College Hill

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About Legacy At College Hill

General Information

Legal Business NameLegal Business Name Not Available
Ownership TypeFor Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareJuly 1, 1969 ()
Capacity96
Residents54
Percent Occupied56%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsBoth
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Legacy At College Hill

Legacy At College Hill
was reviewed by Medicare to have a rating of 2 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of Kansas Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

August 5, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$9,762 fine
FManyPotential for HarmComplaint+InspectionMake sure that the facility is administered in an acceptable way that maintains the well-being of each resident .
FManyPotential for HarmComplaint+InspectionHave enough nurses to care for every resident in a way that maximizes the resident's well being.
FManyPotential for HarmComplaint+InspectionMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
FManyPotential for HarmComplaint+InspectionMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
FManyPotential for HarmComplaint+InspectionDevelop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
FManyPotential for HarmComplaint+Inspection1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
FManyPotential for HarmComplaint+InspectionSet up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
FManyPotential for HarmComplaint+InspectionTrain all employees on what to do in an emergency, and carry out unannounced staff drills.
FManyPotential for HarmComplaint+InspectionHave a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents.
ESomePotential for HarmComplaint+InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
ESomePotential for HarmComplaint+InspectionStore, cook, and serve food in a safe and clean way.
ESomePotential for HarmComplaint+InspectionReasonably accommodate the needs and preferences of each resident.
ESomePotential for HarmComplaint+InspectionHave a program that investigates, controls and keeps infection from spreading.
ESomePotential for HarmComplaint+InspectionKeep all essential equipment working safely.
CManyPotential for Minimal HarmComplaint+InspectionAllow residents to easily view the results of the nursing home's most recent inspection.
DFewPotential for HarmComplaint+InspectionAt least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.
DFewPotential for HarmComplaint+InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
DFewPotential for HarmComplaint+InspectionUpon the death of a resident, convey the residentís personal funds and an accounting of those funds to the appropriate party.
DFewPotential for HarmHealth InspectionGive proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.
DFewPotential for HarmHealth InspectionReview or revise the resident's care plan after any major change in physical or mental health.
DFewPotential for HarmComplaint+InspectionEnsure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care.
DFewPotential for HarmComplaint+InspectionConduct initial and periodic assessments of each resident's functional capacity.
DFewPotential for HarmComplaint+InspectionEnsure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
DFewPotential for HarmComplaint+InspectionAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
DFewPotential for HarmComplaint+InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
DFewPotential for HarmComplaint+InspectionEnsure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.

February 3, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionAn approved installation, maintenance and testing program for fire alarm systems.
FManyPotential for HarmFire Safety InspectionAutomatic sprinkler systems that have been maintained in working order.
DFewPotential for HarmFire Safety InspectionProperly installed electrical wiring and equipment.
DFewPotential for HarmFire Safety InspectionExits that are free from obstructions and can be used at all times.
DFewPotential for HarmFire Safety InspectionProperly located and lighted "Exit" signs.
DFewPotential for HarmFire Safety InspectionSmoke barrier doors that can resist smoke for at least 20 minutes.
DFewPotential for HarmFire Safety InspectionEmergency lighting that can last at least 1 1/2 hours.
DFewPotential for HarmFire Safety InspectionCorridor and hallway doors that block smoke.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Legacy At College Hill require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

2hr 5min
1hr 55min
ReportedExpected
CNA
50min
35min
ReportedExpected
LPN
40min
45min
ReportedExpected
RN
3hr 35min
3hr 20min
ReportedExpected
Total Nursing

This facility also provides approximately 5min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

90.6%
88.1%
88.1%
96.5%
Q1 2015Q2 2015Q3 2015KS
Assessed and Appropriately Given the Seasonal Influenza Vaccine
79.2%
69.0%
59.0%
93.5%
Q1 2015Q2 2015Q3 2015KS
Assessed and Appropriately Given the Pneumococcal Vaccine
-
5.7%
8.8%
40.2%
Q1 2015Q2 2015Q3 2015KS
* The data for this facility for some quarters is unavailable.
Low Risk Residents Who Lose Control of Their Bowel or Bladder
50.0%
50.0%
45.8%
19.9%
Q1 2015Q2 2015Q3 2015KS
Received an Antipsychotic Medication
12.5%
11.5%
28.8%
17.5%
Q1 2015Q2 2015Q3 2015KS
Need for Help with ADLs has Increased
5.8%
3.5%
3.2%
11.0%
Q1 2015Q2 2015Q3 2015KS
Self Report Moderate to Severe Pain
3.8%
7.0%
1.6%
7.4%
Q1 2015Q2 2015Q3 2015KS
Lose Too Much Weight
-
-
-
5.3%
Q1 2015Q2 2015Q3 2015KS
* The data for this facility for some quarters is unavailable.
High Risk Residents With Pressure Ulcers
2.0%
7.0%
8.9%
7.1%
Q1 2015Q2 2015Q3 2015KS
Have Depressive Symptoms
7.7%
3.5%
3.3%
6.6%
Q1 2015Q2 2015Q3 2015KS
With a Urinary Tract Infection
0.0%
0.0%
0.0%
5.0%
Q1 2015Q2 2015Q3 2015KS
Experiencing One or More Falls with Major Injury
4.2%
4.3%
1.9%
3.0%
Q1 2015Q2 2015Q3 2015KS
With a Catheter Inserted and Left in Their Bladder
0.0%
0.0%
0.0%
0.3%
Q1 2015Q2 2015Q3 2015KS
Were Physically Restrained

Quality Measures for Short Stay Residents

10.0%
10.7%
7.4%
77.6%
Q1 2015Q2 2015Q3 2015KS
Assessed and Appropriately Given the Pneumococcal Vaccine
-
20.0%
20.0%
77.9%
Q1 2015Q2 2015Q3 2015KS
* The data for this facility for some quarters is unavailable.
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
-
-
-
21.2%
Q1 2015Q2 2015Q3 2015KS
* The data for this facility for some quarters is unavailable.
Self Report Moderate to Severe Pain
-
-
-
2.7%
Q1 2015Q2 2015Q3 2015KS
* The data for this facility for some quarters is unavailable.
Newly Received an Antipsychotic Medication
0.0%
0.0%
0.0%
1.5%
Q1 2015Q2 2015Q3 2015KS
With Pressure Ulcers That Are New or Worsened