Independent · Federal inspection records, searchable
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Nursing Home Violations Public inspection data, searchable
Facility profile · CCN 175490

Legacy At Herington

45 federal citations on record , including 2 at the Immediate Jeopardy level, and 2 federal enforcement actions totaling $29,273.

2 Immediate Jeopardy

Record summary

Federal record · Q1 2026
45
Total citations
41
Last 3 years
2
Actual harm+
2
Federal penalties
$29,273
Total fines
1
Overall ★ rating

Most common violation categories here

Quality of Care10 Resident Rights9 Medication & Pharmacy6 Nutrition & Dietary5 Administration5

Most common F-tags at this facility

F5503 F6232 F6772 F7562 F7572

Citation history

45 on record
SurveyF-TagViolationSeveritySource
Oct 31, 2024F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.FStandard
Oct 31, 2024F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.FStandard
Oct 31, 2024F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.DStandard
Oct 31, 2024F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.FStandard
Oct 31, 2024F761Ensure 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.DStandard
Oct 31, 2024F758Implement 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.DStandard
Oct 31, 2024F757Ensure each resident’s drug regimen must be free from unnecessary drugs.DStandard
Oct 31, 2024F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.DStandard
Oct 31, 2024F732Post nurse staffing information every day.CStandard
Oct 31, 2024F697Provide safe, appropriate pain management for a resident who requires such services.DStandard
Oct 31, 2024F677Provide care and assistance to perform activities of daily living for any resident who is unable.DStandard
Oct 31, 2024F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.DStandard
Oct 31, 2024F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.DStandard
Oct 31, 2024F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.DStandard
Apr 3, 2024F564Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.DComplaint
Apr 3, 2024F563Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.DComplaint
Apr 3, 2024F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.DComplaint
Sep 20, 2023F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.DComplaint
Sep 20, 2023F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.DComplaint
May 22, 2023F887Educate 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.DComplaint
May 22, 2023F883Develop and implement policies and procedures for flu and pneumonia vaccinations.DComplaint
May 22, 2023F881Implement a program that monitors antibiotic use.FComplaint
May 22, 2023F880Provide and implement an infection prevention and control program.EComplaint
May 22, 2023F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyFComplaint
May 22, 2023F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.FComplaint
May 22, 2023F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.FComplaint
May 22, 2023F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.FComplaint
May 22, 2023F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.FComplaint
May 22, 2023F757Ensure each resident’s drug regimen must be free from unnecessary drugs.DComplaint
May 22, 2023F695Provide safe and appropriate respiratory care for a resident when needed.DComplaint
May 22, 2023F692Provide enough food/fluids to maintain a resident's health.DComplaint
May 22, 2023F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.DComplaint
May 22, 2023F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.JComplaint
May 22, 2023F688Provide 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.DComplaint
May 22, 2023F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.DComplaint
May 22, 2023F677Provide care and assistance to perform activities of daily living for any resident who is unable.EComplaint
May 22, 2023F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.DComplaint
May 22, 2023F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.JComplaint
May 22, 2023F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.DComplaint
May 22, 2023F779Keep signed and dated reports of x-rays and other diagnostic services in the residents record.DStandard
May 22, 2023F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.EStandard
Mar 1, 2023F583Keep residents' personal and medical records private and confidential.DComplaint
Sep 27, 2021F880Provide and implement an infection prevention and control program.DStandard
Sep 27, 2021F695Provide safe and appropriate respiratory care for a resident when needed.DStandard
Sep 27, 2021F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.DStandard

Federal enforcement history

Federal regulators have imposed 2 enforcement actions against this facility, including 1 civil money penalties totaling $29,273 and 1 payment-denial actions spanning 14 days.

DateTypeFinePayment denial
May 22, 2023Fine$29,273—
May 22, 2023Payment Denial—Jun 21, 2023 · 14 days
About this record A citation is a finding by a state survey team working under federal contract. It is not a court judgment. The description above is drawn verbatim from federal public datasets. Facilities have the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.

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