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 51 to 75 of 96 citations

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 September 27, 2021. Found during a standard inspection.
The home gave a date the problem would be corrected (December 20, 2021).
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 September 27, 2021. Found during a standard inspection.
The home gave a date the problem would be corrected (December 20, 2021).
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 September 27, 2021. Found during a standard inspection.
The home gave a date the problem would be corrected (December 20, 2021).
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 September 27, 2021. Found during a standard inspection.
The home gave a date the problem would be corrected (December 20, 2021).
No harm, with potential for more than minimal harm
Ensure that testing and maintenance of electrical equipment is performed.
Widespread (many residents). CMS level F.
Fire safety citation K-0921, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of September 27, 2021. Found during a standard inspection.
The home gave a date the problem would be corrected (December 20, 2021).
No harm, with potential for more than minimal harm
Meet other general requirements.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0100, Construction Deficiencies. Inspection of October 31, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (December 19, 2024).
No harm, with potential for more than minimal harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
Pattern (more than a few residents). CMS level E.
Health citation F-0677, Quality of Life and Care Deficiencies. Inspection of May 22, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (July 5, 2023).
No harm, with potential for more than minimal harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pattern (more than a few residents). CMS level E.
Health citation F-0756, Pharmacy Service Deficiencies. Inspection of May 22, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (July 5, 2023).
No harm, with potential for more than minimal harm
Provide and implement an infection prevention and control program.
Pattern (more than a few residents). CMS level E.
Health citation F-0880, 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).
No harm, with potential for more than minimal harm
Have properly installed electrical wiring and gas equipment.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0511, Services Deficiencies. Inspection of May 22, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (July 17, 2023).
No harm, with potential for more than minimal harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0211, Egress Deficiencies. Inspection of September 27, 2021. Found during a standard inspection.
The home gave a date the problem would be corrected (December 20, 2021).
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.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0321, Smoke Deficiencies. Inspection of September 27, 2021. Found during a standard inspection.
The home gave a date the problem would be corrected (December 20, 2021).
No harm, with potential for more than minimal harm
Inspect, test, and maintain automatic sprinkler systems.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0353, Smoke Deficiencies. Inspection of September 27, 2021. Found during a standard inspection.
The home gave a date the problem would be corrected (December 20, 2021).
No harm, with potential for more than minimal harm
Install corridor and hallway doors that block smoke.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0363, Smoke Deficiencies. Inspection of September 27, 2021. Found during a standard inspection.
The home gave a date the problem would be corrected (December 20, 2021).
No harm, with potential for more than minimal harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0372, Smoke Deficiencies. Inspection of September 27, 2021. Found during a standard inspection.
The home gave a date the problem would be corrected (December 20, 2021).
No harm, with potential for more than minimal harm
Have properly installed electrical wiring and gas equipment.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0511, Services Deficiencies. Inspection of September 27, 2021. Found during a standard inspection.
The home gave a date the problem would be corrected (December 20, 2021).
No harm, with potential for more than minimal harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Isolated (one or a few residents). CMS level D.
Health citation F-0550, Resident Rights Deficiencies. Inspection of October 31, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (November 17, 2024).
No harm, with potential for more than minimal harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Isolated (one or a few residents). CMS level D.
Health citation F-0623, Resident Rights Deficiencies. Inspection of October 31, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (November 17, 2024).
No harm, with potential for more than minimal harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Isolated (one or a few residents). CMS level D.
Health citation F-0657, Resident Assessment and Care Planning Deficiencies. Inspection of October 31, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (November 17, 2024).
No harm, with potential for more than minimal harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
Isolated (one or a few residents). CMS level D.
Health citation F-0677, Quality of Life and Care Deficiencies. Inspection of October 31, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (November 17, 2024).
No harm, with potential for more than minimal harm
Provide safe, appropriate pain management for a resident who requires such services.
Isolated (one or a few residents). CMS level D.
Health citation F-0697, Quality of Life and Care Deficiencies. Inspection of October 31, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (November 17, 2024).
No harm, with potential for more than minimal harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Isolated (one or a few residents). CMS level D.
Health citation F-0756, Pharmacy Service Deficiencies. Inspection of October 31, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (November 17, 2024).
No harm, with potential for more than minimal harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Isolated (one or a few residents). CMS level D.
Health citation F-0757, Pharmacy Service Deficiencies. Inspection of October 31, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (November 17, 2024).
No harm, with potential for more than minimal 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.
Isolated (one or a few residents). CMS level D.
Health citation F-0758, Pharmacy Service Deficiencies. Inspection of October 31, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (November 17, 2024).
No harm, with potential for more than minimal 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.
Isolated (one or a few residents). CMS level D.
Health citation F-0761, Pharmacy Service Deficiencies. Inspection of October 31, 2024. Found during a standard inspection.
The home gave a date the problem would be corrected (November 17, 2024).

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.