All citations for Legacy at Herington

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Legacy at Herington

Last standard health inspection on record

October 31, 2024

This is more than 2 years ago. Newer inspection results may not be on record yet, so the results below may not describe the home today. Ask the home for its most recent inspection report.

Showing 1 to 25 of 41 citations

  1. Immediate jeopardy to resident health or safety

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

    Isolated (one or a few residents). CMS level J.

    Health citation F-0600, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of May 22, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 5, 2023).

  2. Immediate jeopardy to resident health or safety

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Isolated (one or a few residents). CMS level J.

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of May 22, 2023. Found during a standard inspection.

    Past non-compliance: already corrected by the time of the inspection (April 24, 2023).

  3. No harm, with potential for more than minimal harm

    Have properly installed electrical wiring and gas equipment.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0511, Services Deficiencies. Inspection of March 28, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (April 10, 2025).

  4. No harm, with potential for more than minimal harm

    Ensure proper usage of power strips and extension cords.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0920, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of March 28, 2025. Found during a complaint inspection.

    The home gave a date the problem would be corrected (April 10, 2025).

  5. No harm, with potential for more than minimal 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.

    Widespread (many residents). CMS level F.

    Health citation F-0801, Nutrition and Dietary Deficiencies. Inspection of May 22, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 5, 2023).

  6. No harm, with potential for more than minimal harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Widespread (many residents). CMS level F.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of May 22, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 5, 2023).

  7. No harm, with potential for more than minimal harm

    Administer the facility in a manner that enables it to use its resources effectively and efficiently.

    Widespread (many residents). CMS level F.

    Health citation F-0835, Administration Deficiencies. Inspection of May 22, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 5, 2023).

  8. No harm, with potential for more than minimal harm

    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

    Widespread (many residents). CMS level F.

    Health citation F-0867, Administration Deficiencies. Inspection of May 22, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 5, 2023).

  9. No harm, with potential for more than minimal harm

    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

    Widespread (many residents). CMS level F.

    Health citation F-0868, Administration Deficiencies. Inspection of May 22, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 5, 2023).

  10. No harm, with potential for more than minimal harm

    Implement a program that monitors antibiotic use.

    Widespread (many residents). CMS level F.

    Health citation F-0881, Infection Control Deficiencies. Inspection of May 22, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 5, 2023).

  11. No harm, with potential for more than minimal harm

    Conduct testing and exercise requirements.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0039, Emergency Preparedness Deficiencies. Inspection of May 22, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 17, 2023).

  12. No harm, with potential for more than minimal harm

    Meet other general requirements.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0100, Construction Deficiencies. Inspection of May 22, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 17, 2023).

  13. No harm, with potential for more than minimal harm

    Use approved construction type or materials.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0161, Construction Deficiencies. Inspection of May 22, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 17, 2023).

  14. No harm, with potential for more than minimal harm

    Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0222, Egress Deficiencies. Inspection of May 22, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 17, 2023).

  15. No harm, with potential for more than minimal harm

    Install emergency lighting that can last at least 1 1/2 hours.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0291, Egress Deficiencies. Inspection of May 22, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 17, 2023).

  16. No harm, with potential for more than minimal harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0321, Smoke Deficiencies. Inspection of May 22, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 17, 2023).

  17. No harm, with potential for more than minimal harm

    Provide properly protected cooking facilities.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0324, Smoke Deficiencies. Inspection of May 22, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 17, 2023).

  18. No harm, with potential for more than minimal harm

    Have approved installation, maintenance and testing program for fire alarm systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0345, Smoke Deficiencies. Inspection of May 22, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 17, 2023).

  19. No harm, with potential for more than minimal harm

    Inspect, test, and maintain automatic sprinkler systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of May 22, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 17, 2023).

  20. No harm, with potential for more than minimal harm

    Properly select, install, inspect, or maintain portable fire extinguishes.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0355, Smoke Deficiencies. Inspection of May 22, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 17, 2023).

  21. No harm, with potential for more than minimal harm

    Install corridor and hallway doors that block smoke.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0363, Smoke Deficiencies. Inspection of May 22, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 17, 2023).

  22. No harm, with potential for more than minimal harm

    Have simulated fire drills held at unexpected times.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of May 22, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 17, 2023).

  23. No harm, with potential for more than minimal harm

    To conduct inspection, testing and maintenance of fire doors by qualified individuals.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0761, Miscellaneous Deficiencies. Inspection of May 22, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 17, 2023).

  24. No harm, with potential for more than minimal harm

    Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0914, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of May 22, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 17, 2023).

  25. No harm, with potential for more than minimal harm

    Ensure proper usage of power strips and extension cords.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0920, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of May 22, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 17, 2023).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of October 1, 2026. Inspection results describe the home at the time of each inspection.