Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Legacy At Herington during CMS and state inspections, most recent first.
The facility did not employ a full-time certified dietary manager, placing 31 residents at risk for inadequate nutrition. Dietary Staff BB, who was not certified, was managing the kitchen operations. This was against the facility's policy, which required a certified dietary manager to oversee food and nutrition services.
The facility was found to have unsanitary kitchen conditions, including a greasy air vent grill and disrepair of fluorescent light fixtures, posing a risk for food-borne illness among 31 residents. Maintenance staff confirmed these issues, which violated the facility's sanitization policy.
The facility failed to submit accurate staffing information through PBJ, with reports indicating no licensed nurse coverage on several days across different fiscal quarters. Despite payroll data showing 24/7 licensed nurse coverage, discrepancies were acknowledged by administrative staff, highlighting a failure to adhere to reporting requirements and placing residents at risk for inadequate staffing.
The facility failed to maintain the dignity of two residents. A resident received a blood sugar check and insulin injection in a common area, violating privacy policies. Another resident, with cognitive impairments, was repeatedly observed with unkempt hair and clothing, despite needing assistance with grooming. These actions did not align with the facility's dignity policy.
A facility failed to notify the State Long Term Care Ombudsman of a resident's discharge to the hospital. The resident, with a history of dementia and major depressive disorder, was sent to the emergency department after an incident involving self-harm behavior. The facility's Social Services staff were unaware of the requirement to notify the Ombudsman for hospital discharges, and the facility lacked a policy on this matter, leading to the oversight.
A resident with Alzheimer's and severely impaired cognition was frequently incontinent, yet her care plan lacked instructions for toileting assistance after meals. Despite staff awareness of her needs, the care plan was not updated, leading to an incontinent episode and placing her at risk for impaired care.
A resident with severe cognitive impairment did not receive consistent bathing and toileting assistance, as required by their care plan. Despite the resident's refusal of showers due to feeling cold, the facility did not offer alternative bathing methods. Additionally, the resident was not assisted with toileting after meals, leading to incontinence. These failures placed the resident at risk for poor hygiene and related complications.
A resident with Alzheimer's and thoracic spine pain experienced inadequate pain management due to staff's failure to communicate and administer prescribed medications. Despite frequent complaints of back pain, the resident's pain was not effectively addressed, as CNAs did not report the pain to the nurse or CMA, and the scheduled acetaminophen was not administered as required.
A facility failed to ensure the Consultant Pharmacist identified and reported the lack of appropriate indication for antipsychotic medication use in a resident with MDD and irregularities in blood sugar monitoring for a diabetic resident. The pharmacist's monthly reviews did not address these issues, placing residents at risk for ineffective medication regimens and side effects.
The facility failed to monitor and provide necessary interventions for bowel management for a resident with impaired cognition, leading to extended periods without bowel movements. Additionally, the facility did not notify a physician when another resident's blood sugar levels exceeded ordered parameters, risking unnecessary medication side effects. These deficiencies highlight a lack of adherence to physician orders and protocols.
A resident with dementia and major depressive disorder was administered Seroquel, an antipsychotic medication, without appropriate indication or documented physician rationale. The facility's policy required addressing various causes of behavioral symptoms before considering antipsychotic use, but this was not followed, placing the resident at risk for adverse side effects.
A facility failed to label insulin flex pens for three residents with the dates they were opened and the discard dates, as observed during a treatment cart inspection. Both a licensed nurse and an administrative nurse confirmed the requirement for such labeling. The facility's policy and Medlineplus.gov guidelines state that open, unrefrigerated insulin must be used within 28 days. This oversight risked the residents receiving ineffective medication.
The facility failed to properly prepare pureed diets for three residents, compromising the meals' nutritive value and palatability. A dietary staff member did not include bread or rolls in the pureed meals, as required by the facility's policy, resulting in residents not receiving the same nutritional value as those on the general diet.
The facility did not display current daily nursing staff hours as required by policy. On two consecutive days, the posted hours were outdated, showing information from a previous date. An administrative nurse confirmed that the night shift nurse responsible for updating the staffing hours had not posted the correct information. The facility's policy mandates daily posting of nursing personnel numbers for each shift.
A resident with intact cognition was taken outside for his scheduled vape time by an LPN. During this time, an administrative staff member confronted the LPN in front of the resident, stating that the resident's vaping was not a priority. This interaction made the resident feel insecure, unimportant, and belittled, violating the facility's dignity policy.
The facility failed to ensure that two residents were able to exercise their right to receive visitors of their choosing at the time of their choice. One resident was restricted from receiving visits from her representative without prior scheduling and supervision, while another resident's husband was barred from the dining room after an outburst. These actions were not in line with the facility's visitation policy, placing the residents at risk for impaired rights and social isolation.
The facility failed to inform two residents and/or their representatives of visitation restrictions, leading to emotional distress and impaired resident rights. One resident with severe cognitive impairment and another with intact cognition were affected, with no formal notices issued as required by the facility's visitation policy.
Lack of Certified Dietary Manager in Facility
Penalty
Summary
The facility failed to provide the services of a full-time certified dietary manager for its 31 residents, which placed them at risk for inadequate nutrition. During an observation, it was noted that the dietary staff in the kitchen were preparing meals without the oversight of a certified dietary manager. Dietary Staff BB, who was acting as the dietary manager, confirmed that she was not certified. This was further verified by Administrative Staff A, who acknowledged that the facility did not have a certified dietary manager. The facility's policy, dated 10/2017, required a qualified dietician to oversee food and nutrition services, and if a dietician was not employed full-time, a certified dietary manager should be designated. The policy outlined specific qualifications for this role, including certification in dietary or food service management. The absence of a certified dietary manager meant that the facility did not meet its own policy requirements, thereby failing to adequately evaluate residents' nutritional needs and oversee food-related operations.
Unsanitary Kitchen Conditions
Penalty
Summary
The facility, with a census of 31 residents, was found to have unsanitary conditions in its kitchen, which posed a risk for food-borne illness among the residents. During an initial tour, surveyors observed a three-foot by six-inch air vent grill above the North door entrance to the kitchen covered with a brownish grease/sticky substance and a gray fuzzy substance, which was blowing directly onto the food preparation area. Additionally, two fluorescent light fixtures located in the exhaust hood above the stovetop were found to be in disrepair; one cover was missing, exposing the fluorescent bulb, and the other cover was partially affixed. Further observations revealed nine ceiling-mounted fluorescent light fixtures with metal pull chains that had a brownish-gray fuzzy substance affixed to them, located directly above the food preparation and dishwashing areas. Maintenance staff confirmed the unsanitary conditions, including the dirty register grill, the dirty overhead fluorescent light pull chains, and the missing and partially affixed fluorescent light covers. The facility's Sanitization policy, dated October 2008, required the food service area to be maintained in a clean and sanitary manner, but the facility failed to adhere to these standards, placing residents at risk for food-borne illness.
Inaccurate PBJ Data Submission
Penalty
Summary
The facility failed to submit complete and accurate staffing information through Payroll-Based Journaling (PBJ) as required by CMS. The PBJ reports for various fiscal quarters indicated that there were days with no licensed nurse coverage, specifically on eight days in FY 2023 Q4, eight days in FY 2024 Q3, and six days in FY 2024 Q1. However, a review of the facility's licensed nurse payroll data for these dates revealed that a licensed nurse was on duty 24 hours a day, seven days a week. This discrepancy suggests that the facility did not accurately report its staffing data to CMS. Administrative Staff A acknowledged that there might have been instances where incorrect information was submitted, confirming the inaccuracies in the reported dates. Despite the facility's policy, which mandates the electronic reporting of direct care staffing information to CMS, including details about the category of work and hours worked, the facility failed to adhere to these requirements. This failure to submit accurate PBJ data placed the residents at risk for unidentified and ongoing inadequate staffing.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to provide care for two residents in a manner that protected and promoted their dignity. For one resident, a licensed nurse checked the resident's blood sugar and administered an insulin injection in a common area, where other residents and staff were present. This action was contrary to the facility's policy, which requires such procedures to be conducted in private to maintain the resident's dignity and respect. Another resident, who had a cognitive communication deficit and required assistance with personal care, was observed multiple times with disheveled and greasy hair, dried food on her clothing, and unshaven chin hair. Despite the care plan directing staff to assist with grooming, the resident was brought to common areas without adequate grooming, failing to uphold the dignity policy that mandates residents be groomed as they wish and treated with respect.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman (LTCO) of a facility-initiated discharge of a resident to the hospital. The resident, identified as R25, had a history of dementia, major depressive disorder (MDD), and a traumatic subdural hematoma. The resident's care plan included the administration of antipsychotic medication and monitoring for side effects. On a particular day, the resident was observed attempting to sharpen a shaving razor, which led to an assessment by the nurse and a subsequent decision to send the resident to the emergency department for evaluation. The resident was later transported to a behavioral health hospital for further psychiatric evaluation. The clinical record for the resident lacked documentation that the LTCO was notified of the discharge. Social Services staff stated that they were unaware of the requirement to notify the LTCO of discharges to the hospital, as they only reported residents discharged home. The facility did not provide a policy regarding the discharge of residents or the notification of the Ombudsman, which contributed to the oversight. This failure to notify the LTCO placed the resident at risk for impaired rights.
Failure to Update Care Plan for Resident's Toileting Needs
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R2, to adequately address her toileting needs. R2, who has diagnoses including Alzheimer's disease and severely impaired cognition, was documented as frequently incontinent of bladder and bowel. Despite this, her care plan did not include specific instructions for staff to assist her with toileting after every meal. Observations and interviews revealed that R2 expressed a need to use the bathroom but was not assisted in time, resulting in an incontinent episode. Staff members, including CNAs and administrative nurses, acknowledged that R2 required assistance with toileting before and after meals, but this was not reflected in her care plan. The facility's policy mandates that care plans be individualized and updated to reflect the resident's needs, especially when there is a significant change or unmet desired outcomes. However, the care plan for R2 lacked the necessary updates to guide staff on her toileting schedule, placing her at risk for impaired care due to uncommunicated needs. The failure to revise the care plan as per the facility's policy led to the deficiency identified by the surveyors.
Failure to Provide Adequate Hygiene and Toileting Assistance
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for a resident, identified as R2, who had severe cognitive impairment due to Alzheimer's disease. R2 required supervision with activities of daily living, including bathing, dressing, and toileting. Despite the care plan directing staff to encourage bathing twice a week and provide peri-care with every incontinent episode, R2 did not receive a bath or shower for extended periods, specifically from late September to mid-October and again from mid to late October. The EMR noted that R2 refused showers on several occasions, and staff acknowledged that R2 often refused showers due to feeling cold and a possible past incident related to water. However, the facility did not offer alternative bathing methods to accommodate R2's needs and preferences. Additionally, the facility failed to assist R2 with toileting after meals, as required by her care plan. Observations revealed instances where R2 expressed the need to use the bathroom but was not assisted in time, resulting in incontinence. Staff interviews confirmed that R2 required assistance with toileting before and after meals, but the care plan did not reflect this need. The facility's policy on activities of daily living emphasized providing appropriate support to maintain personal hygiene and addressing cognitive impairments by identifying underlying causes of care resistance. However, the facility did not consistently apply these guidelines, placing R2 at risk for poor hygiene and related complications.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to adequately respond to a resident's complaints of pain, placing the resident at risk for unresolved pain and discomfort. The resident, who had diagnoses including Alzheimer's disease, thoracic spine pain, and hyperthyroidism, was documented to have severely impaired cognition and required supervision for various activities. Despite having physician orders for pain management, including scheduled and as-needed medications, the resident's pain was not effectively managed. Observations revealed that the resident frequently complained of back pain, yet the Certified Nurse Aide (CNA) did not report these complaints to the nurse or Certified Medication Aide (CMA). The facility's records showed that the resident had a care plan directing staff to administer pain medications as ordered and to document the effectiveness of interventions. However, the Medication Administration Record (MAR) indicated that the scheduled acetaminophen was not administered as required. Interviews with staff revealed a lack of communication regarding the resident's pain, with the CMA unaware of the resident's pain complaints and scheduled medication. The facility's Pain-Clinical Protocol required staff to assess and document pain, but these procedures were not followed, leading to inadequate pain management for the resident.
Consultant Pharmacist Fails to Identify Medication and Monitoring Irregularities
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported the lack of an appropriate indication for the continued use of antipsychotic medication Seroquel for a resident diagnosed with Major Depressive Disorder (MDD). The resident's Electronic Medical Record (EMR) lacked documented physician rationale for the use of Seroquel, including unsuccessful attempts for non-pharmacological symptom management and risk versus benefits analysis. Despite monthly medication reviews by the CP, there was no evidence of a recommendation for an appropriate indication for the continued use of Seroquel over several months. Additionally, the facility did not ensure that the CP identified and reported irregularities in blood sugar monitoring for another resident diagnosed with diabetes mellitus. The resident's Diabetic Monitoring Record showed multiple instances where blood sugar levels were out of the physician-ordered parameters, yet the physician was not notified. The CP's Medication Regimen Review for the months of August and September lacked evidence of identifying and reporting these out-of-parameter blood sugars. These deficiencies placed the residents at risk for physical decline, ineffective medication regimens, and side effects from unnecessary medication. The facility's policies required the CP to review each resident's drug regimen monthly and report any irregularities, but these requirements were not met, leading to the identified deficiencies.
Failure to Monitor Bowel Management and Blood Sugar Levels
Penalty
Summary
The facility failed to adequately monitor and provide necessary interventions for bowel management for a resident with severely impaired cognition and a history of constipation. Despite having a physician's order to administer Milk of Magnesia as needed for constipation, the resident's bowel monitoring records showed multiple instances of extended periods without bowel movements, ranging from four to eleven consecutive days. The Medication Administration Records lacked documentation of the administration of the ordered interventions during these periods. Staff interviews revealed that the resident was not a reliable historian due to cognitive impairment, and staff failed to perform bowel assessments or administer the prescribed laxatives, placing the resident at risk for impaction and physical decline. Another deficiency involved the failure to notify a physician when a resident's blood sugar levels were outside the physician-ordered parameters. The resident, who had diagnoses including diabetes mellitus and severely impaired cognition, had several instances where blood sugar levels exceeded the set threshold, yet the physician was not notified as required. The Diabetic Monitoring Records documented multiple occurrences of elevated blood sugar levels without physician notification, and there were also instances where blood sugar levels were not obtained as ordered. Staff interviews indicated a lack of awareness regarding the documentation of blood sugar levels and the necessity to follow physician orders. These deficiencies highlight the facility's failure to adhere to physician orders and protocols for monitoring and managing residents' medical conditions. The lack of appropriate interventions and communication with physicians placed the residents at risk for unnecessary medication side effects and other related complications.
Inappropriate Use of Antipsychotic Medication Without Proper Indication
Penalty
Summary
The facility failed to ensure an appropriate indication or a documented physician rationale for the continued use of antipsychotic medication for a resident diagnosed with major depressive disorder (MDD). The resident, who had a history of dementia, major depressive disorder, and a traumatic subdural hematoma, was receiving Seroquel, an antipsychotic medication, without documented unsuccessful attempts for nonpharmacological symptom management or a risk versus benefits analysis. The resident's care plan indicated that a gradual dose reduction review would be completed by the pharmacist and physician, but the electronic medical record lacked the necessary documentation to justify the continued use of the medication. Observations and interviews revealed that the resident was administered Seroquel despite the absence of an approved indication for its use in treating MDD. The facility's policy on antipsychotic medication use required that such medications be considered only after addressing medical, physical, functional, psychological, emotional, psychiatric, social, and environmental causes of behavioral symptoms. However, the facility did not adhere to this policy, as the resident continued to receive the medication without the required physician documentation, placing the resident at risk for adverse side effects.
Failure to Label Insulin Flex Pens with Opened and Discard Dates
Penalty
Summary
The facility failed to properly label insulin flex pens for three residents, identified as R6, R14, and R26, with the dates they were opened and the discard dates. This oversight was discovered during an observation of the facility's treatment cart, where it was noted that the Basaglar and Lantus insulin flex pens for these residents lacked the necessary labeling. Both a licensed nurse and an administrative nurse confirmed that the insulin pens should have been labeled with the date they were opened and the expiration date. According to Medlineplus.gov, open and unrefrigerated Lantus (including Basaglar and glargine) must be used within 28 days, after which it should be discarded. The facility's own medication storage policy, dated November 2020, mandates that all drugs and biologicals be stored safely and securely, and that outdated or deteriorated drugs should not be used. The failure to label the insulin flex pens with the opened and discard dates placed the residents at risk for receiving ineffective medication.
Failure to Properly Prepare Pureed Diets
Penalty
Summary
The facility failed to correctly prepare a pureed diet for three residents, which compromised the nutritive value and palatability of the meals provided. During an observation, it was noted that the dietary staff member, DS CC, prepared pureed meals by blending cheesy macaroni hamburger helper with beef base, resulting in a thin consistency. The pureed food was then placed in a hot water well for holding. Additionally, DS CC prepared pureed pears and carrots, but did not include bread or rolls in the pureed diet, which was part of the general diet menu. This omission was confirmed by another dietary staff member, DS BB, who acknowledged that DS CC forgot to include these items due to nervousness. The facility's Pureed Diet policy, dated January 2014, specifies that a pureed diet should be smooth in consistency and should include all components of the general diet, modified as necessary. The policy also states that bread or rolls should be pureed with the meal if they are part of the general diet. The failure to adhere to this policy resulted in the affected residents not receiving the same nutritional value as those on the general diet, placing them at risk for impaired nutrition. The deficiency was identified through observation, record review, and interviews, highlighting a lapse in the facility's dietary practices for residents requiring pureed diets.
Failure to Post Current Daily Nursing Staff Hours
Penalty
Summary
The facility failed to display current daily nursing staff hours as required by their policy. On two consecutive days, the posted nurse staff hours were outdated, showing information from a previous date. This was observed on 10/29/24 and 10/30/24, where the posted hours were dated 10/28/24. An interview with Administrative Nurse E on 10/31/24 confirmed that the night shift nurse, who was responsible for updating the daily nurse staffing hours, had not posted the correct information for those days. The facility's policy, dated 07/16, mandates that the number of nursing personnel responsible for providing direct care to residents be posted daily for each shift. The failure to update the staffing information as required led to this deficiency.
Failure to Treat Resident with Dignity
Penalty
Summary
The facility failed to ensure that a resident, identified as R3, was treated with dignity. R3, who had a diagnosis of nontraumatic intracerebral hemorrhage and intact cognition, was taken outside by a Licensed Nurse (LN) H for his scheduled vape time. During this time, Administrative Staff A confronted LN H in front of R3, questioning why she was outside and stating that R3's vaping was not a priority. This interaction made R3 feel insecure, unimportant, and belittled. R3 expressed that the nurses were supposed to make residents a priority, and the comment from Administrative Staff A made him feel terrible and unwanted. The facility's Dignity policy, revised in February 2021, directed that residents be treated with respect and dignity at all times. However, the incident on 02/29/24, where Administrative Staff A confronted LN H in front of R3, violated this policy. The conversation, which R3 overheard, led to feelings of decreased dignity and self-worth for R3. The facility's failure to uphold its dignity policy placed R3 at risk for impaired psychosocial well-being.
Failure to Ensure Resident Visitation Rights
Penalty
Summary
The facility failed to ensure that two residents, R1 and R2, were able to exercise their right to receive visitors of their choosing at the time of their choice. R1, who had severe cognitive impairment due to a stroke, was restricted from receiving visits from her representative without prior scheduling and supervision. This restriction was based on an unverified email from the State Agency (SA) that mentioned substantiated neglect. The facility did not clarify the information with the SA before imposing the restriction, leading to an incident where law enforcement was called to remove R1's representative during an unscheduled visit. R2, who had intact cognition, was also restricted from receiving visits from her husband in the dining room. The restriction was imposed after a dietary staff member felt uncomfortable due to an outburst from R2's husband when he was denied seconds. The facility refunded the money R2's husband had paid for meals and told him he could no longer eat at the facility. R2 expressed that her husband made her feel comfortable and that the restriction made her feel uncomfortable and led to her crying during an interview with the surveyor. The facility's visitation policy, revised in September 2022, directed that residents were permitted to have visitors of their choosing at the time of their choosing and provided 24-hour access to visitors with the resident's consent. The facility's failure to adhere to this policy placed both R1 and R2 at risk for impaired resident rights, impaired psychosocial well-being, and social isolation.
Failure to Inform Residents of Visitation Restrictions
Penalty
Summary
The facility failed to inform two residents and/or their representatives of their visitation rights and any restrictions placed on them. Resident 1, who had severe cognitive impairment, was not provided with a notice regarding restricted visitation for her durable power of attorney (DPOA). The DPOA was told by the facility's administrative staff that she could only visit Resident 1 by appointment and under supervision, but no formal notice was issued. This led to a situation where law enforcement was called when the DPOA visited outside the scheduled time, causing distress to Resident 1 and her representative. Resident 2, who had intact cognition, was also not informed of visitation restrictions placed on her husband. The facility told Resident 2's husband that he could not eat in the dining room and had to wait until Resident 2 finished eating. This restriction was imposed after an incident where dietary staff felt uncomfortable due to an outburst by Resident 2's husband. Despite this, no formal notice was given to Resident 2 or her representative about the visitation restrictions, leading to emotional distress for Resident 2. The facility's visitation policy, revised in September 2022, stated that residents were permitted to have visitors of their choosing at any time, with 24-hour access provided. However, the facility failed to adhere to this policy by not issuing the required notices to the residents and their representatives, thereby impairing resident rights, psychosocial well-being, and increasing the risk of social isolation.
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Illustrative
What surveyors actually found near you
We read the 47 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Herington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Enterprise Estates Nuring Center | 17.7 mi | ★★★★★ | 20 | 0 |
| Chapman Valley Manor | 21.1 mi | ★★★★★ | 0 | 0 |
| Memorial Hospital Ltcu (village Manor) | 22 mi | ★★★★★ | 0 | 0 |
| St Luke Living Center | 23.5 mi | ★★★★★ | 19 | 0 |
| Diversicare Of Council Grove | 23.6 mi | ★★★★★ | 0 | 0 |
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