About Legacy at College Hill
Legacy At College Hill, located in WICHITA, KS, is a for-profit organization that accepts Medicare and Medicaid.
Why Families Choose Legacy at College Hill
Key Performance Indicators
- CMS Overall Rating 1 Stars
- Nursing Hours 3.82 hrs
- Safety Record Clean
Chain Affiliations & Network
This facility is part of the CAMPBELL STREET SERVICES network. This chain operates 20 facilities.
Chain Performance Overview
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Nursing Staff Analysis
Staffing levels are a critical indicator of quality care. We analyze the daily hours of care provided by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs).
Below Average Staffing
Legacy at College Hill provides less care hours than the state average and less than the national average.
Registered Nurses (RN)
Licensed Practical Nurses
Certified Assistants
CMS Quality Ratings
| Category | Rating | Stars |
|---|---|---|
| Overall Rating | 1 |
|
| Health Inspection | 1 |
|
| Quality Measures | 3 |
|
| Staffing | 3 |
|
Health Inspection History
| Inspection Cycle | Score | Date |
|---|---|---|
| Cycle 1 (Most Recent) | 116 | Feb 13, 2025 |
| Weighted Average | 271 | Combined Score |
Detailed Quality Measures
Rates are from CMS quality measures (claims-based and MDS-based) for the reporting period ending May 01, 2026. Some measures may be omitted when CMS does not report a numeric rate for this facility.
Medicare claims-based measures
Typically includes short-stay outcomes, hospitalizations, and ED use from Medicare claims.
| Measure | Rate |
|---|---|
| Percentage of short-stay residents who were rehospitalized after a nursi... (QM521) | 11.1% |
| Percentage of short-stay residents who had an outpatient emergency depar... (QM522) | 10.7% |
| Number of hospitalizations per 1000 long-stay resident days (QM551) | 2.8% |
| Number of outpatient emergency department visits per 1000 long-stay resi... (QM552) | 1.9% |
MDS-based measures
Resident assessment data; often used for long-stay care quality.
| Measure | Rate |
|---|---|
| Percentage of long-stay residents whose need for help with daily activit... (QM401) | 12.6% |
| Percentage of long-stay residents who lose too much weight (QM404) | 10.1% |
| Percentage of long-stay residents with a catheter inserted and left in t... (QM406) | 0.0% |
| Percentage of long-stay residents with a urinary tract infection (QM407) | 1.9% |
| Percentage of long-stay residents who have depressive symptoms (QM408) | 1.3% |
| Percentage of long-stay residents who were physically restrained (QM409) | 0.0% |
| Percentage of long-stay residents experiencing one or more falls with ma... (QM410) | 4.5% |
| Percentage of long-stay residents assessed and appropriately given the p... (QM415) | 95.5% |
| Percentage of short-stay residents assessed and appropriately given the... (QM430) | 78.8% |
| Percentage of short-stay residents who newly received an antipsychotic m... (QM434) | 0.0% |
| Percentage of long-stay residents whose ability to walk independently wo... (QM451) | 6.3% |
| Percentage of long-stay residents who received an antianxiety or hypnoti... (QM452) | 20.2% |
| Percentage of long-stay residents assessed and appropriately given the s... (QM454) | 98.6% |
| Percentage of short-stay residents who were assessed and appropriately g... (QM472) | N/A |
| Percentage of long-stay residents with pressure ulcers (QM479) | 6.0% |
| Percentage of long-stay residents with new or worsened bowel or bladder... (QM480) | 8.0% |
| Percentage of long-stay residents who received an antipsychotic medicati... (QM481) | 20.4% |
Complaints & Deficiencies
Complaint History by Year
This chart shows the number of complaints filed each year.
Summary:
- 2023: 24 complaints
- 2024: 6 complaints
- 2025: 17 complaints
- Total: 47 complaints on record
Recent Complaints (Since Jan 2023)
| Date | Description |
|---|---|
| Jun 20, 2025 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. |
| Jun 20, 2025 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. |
| Jun 20, 2025 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. |
| Mar 07, 2025 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. |
| Mar 07, 2025 | Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. |
| Mar 07, 2025 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. |
| Mar 07, 2025 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. |
| Mar 07, 2025 | Provide safe, appropriate dialysis care/services for a resident who requires such services. |
| Mar 07, 2025 | Provide care or services that was trauma informed and/or culturally competent. |
| Mar 07, 2025 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. |
| Mar 07, 2025 | Ensure each resident?s drug regimen must be free from unnecessary drugs. |
| Mar 07, 2025 | 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. |
| Mar 07, 2025 | 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. |
| Mar 07, 2025 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. |
| Mar 07, 2025 | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. |
| Mar 07, 2025 | Provide and implement an infection prevention and control program. |
| Mar 07, 2025 | Develop and implement policies and procedures for flu and pneumonia vaccinations. |
| Aug 23, 2024 | Provide and implement an infection prevention and control program. |
| Aug 23, 2024 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. |
| Aug 23, 2024 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. |
| Aug 23, 2024 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. |
| Aug 23, 2024 | Provide appropriate treatment and care according to orders, resident?s preferences and goals. |
| Aug 23, 2024 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. |
| Jun 15, 2023 | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. |
| Jun 15, 2023 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. |
| Jun 15, 2023 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. |
| Jun 15, 2023 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. |
| Jun 15, 2023 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. |
| Jun 15, 2023 | Respond appropriately to all alleged violations. |
| Jun 15, 2023 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. |
| Jun 15, 2023 | Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. |
| Jun 15, 2023 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. |
| Jun 15, 2023 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. |
| Jun 15, 2023 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. |
| Jun 15, 2023 | Ensure that the resident and his/her doctor meet face-to-face at all required visits. |
| Jun 15, 2023 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. |
| Jun 15, 2023 | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. |
| Jun 15, 2023 | Observe each nurse aide's job performance and give regular training. |
| Jun 15, 2023 | Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. |
| Jun 15, 2023 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. |
| Jun 15, 2023 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. |
| Jun 15, 2023 | 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. |
| Jun 15, 2023 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. |
| Jun 15, 2023 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. |
| Jun 15, 2023 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly |
| Jun 15, 2023 | Provide and implement an infection prevention and control program. |
| Jun 15, 2023 | Make sure that a working call system is available in each resident's bathroom and bathing area. |
Nearby Hospitals
ASCENSION VIA CHRISTI HOSPITALS WICHITA, INC.
WICHITA, KS
KANSAS MEDICAL CENTER LLC
ANDOVER, KS
MERCY HOSPITAL PITTSBURG, INC
PITTSBURG, KS
WESLEY MEDICAL CENTER
WICHITA, KS
KANSAS HEART HOSPITAL
WICHITA, KS
VIA CHRISTI HOSPITAL WICHITA ST TERESA, INC
WICHITA, KS
ROCK REGIONAL HOSPITAL, LLC
DERBY, KS
WICHITA VA MEDICAL CENTER
WICHITA, KS
NMC HEALTH
NEWTON, KS
SUSAN B ALLEN MEMORIAL HOSPITAL
EL DORADO, KS
KANSAS SURGERY & RECOVERY CENTER
WICHITA, KS
KANSAS SPINE & SPECIALTY HOSPITAL, LLC
WICHITA, KS
CORTERRA OF WICHITA LLC
WICHITA, KS
ST VERONICA
BEL AIRE, KS
Owner & Operator Information
Business Entity
COLLEGE HILLS OPCO, LLC
Ownership Structure
Management & Direction
- JOHN ADAMS ADP OF THE SNF
- RODNEY BRYANT OPERATIONAL/MANAGERIAL CONTROL
- RODNEY BRYANT ADP OF THE SNF
- CAMPBELL STREET SERVICES LLC OPERATIONAL/MANAGERIAL CONTROL
- CAMPBELL STREET SERVICES LLC ADP OF THE SNF
- COLLEGE HILLS REALCO LLC ADP OF THE SNF
- ISAAC DOLE ADP OF THE SNF
- ISAAC DOLE CORPORATE OFFICER
- JORDAN FISHFELD ADP OF THE SNF
- AMY FOX OPERATIONAL/MANAGERIAL CONTROL
- AMY FOX ADP OF THE SNF
- STEVEN GRIFFIN OPERATIONAL/MANAGERIAL CONTROL
- STEVEN GRIFFIN ADP OF THE SNF
- KS PORTFOLIO INVESTOR LLC ADP OF THE SNF
- KS PORTFOLIO MANAGER LLC OPERATIONAL/MANAGERIAL CONTROL
- KS PORTFOLIO MASTER HOLDCO LLC ADP OF THE SNF
- KS PORTFOLIO MASTER SNF HOLDCO LLC ADP OF THE SNF
- ISIDORE MENDELOVITZ ADP OF THE SNF
- NKERO INVESTMENTS LTD LLP ADP OF THE SNF
- SANJAY TOLIA ADP OF THE SNF
- VINAY TOLIA ADP OF THE SNF
Associated Doctors
Local Comparison
| Facility | Distance | Rating |
|---|---|---|
| Villa Maria | N/A | 5 |
| Caritas Center, Inc | N/A | 5 |
| Derby Health and Rehabilitation, LLC | N/A | 5 |
| Bethel Health Care Center | N/A | 5 |
| Regent Park Rehabilitation and Healthcare | N/A | 5 |
| Larksfield Place | N/A | 5 |
| Mount St Mary | N/A | 5 |
| Ascension Living Via Christi Village Mclean | N/A | 5 |
| Family Health and Rehabilitation Center | N/A | 4 |
| Wichita Presbyterian Manor | N/A | 5 |
Related Analysis
Best Nursing Homes in WICHITA, KS
Compare Legacy at College Hill to the top-rated facilities in the area.
Ownership Details
Complete list of registered owners, including direct and indirect ownership.
Noted Deficiencies
Detailed history of deficiencies with descriptions and correction dates.
Nursing Hours Analysis
Detailed breakdown of staffing hours per resident by role.
Frequently Asked Questions
- Skilled Nursing Care: 24/7 medical supervision and complex medical treatments
- Long-term Residential Care: Assistance with daily living activities for extended stays
- Short-term Rehabilitation: Recovery services after hospital stays or surgeries
- Memory Care: Specialized programs for residents with dementia and Alzheimer's disease
- Level of care needed (skilled nursing vs. long-term care)
- Room type (private vs. semi-private)
- Insurance coverage (Medicare, Medicaid, private insurance)
- Length of stay and specific services required
For current rates and to discuss payment options, contact Legacy at College Hill directly at 3166859291. Their admissions team can help determine coverage and out-of-pocket expenses.
Environment & Cleanliness
- Overall cleanliness and odors
- Resident room conditions
- Common area maintenance
- Safety features and accessibility
Staff & Care Quality
- Staff-to-resident ratios
- How staff interact with residents
- Response time to resident needs
- Staff knowledge and professionalism
Ask to speak with current residents and their families, tour at different times of day, and review the facility's most recent inspection reports.