Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

LEGACY AT HERINGTON

HERINGTON, KS · 45 certified beds · Last Life Safety survey March 28, 2025

CMS Certification Number 175490 · first certified May 2006

Ownership

Operated by CAMPBELL STREET SERVICES · For profit - Individual

No change of ownership on CMS record since January 1, 2016, when the records begin.

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within KS

54 citations — more than 97% of the 296 certified nursing homes in KS. Compared within KS rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 2 citations; the earlier surveys in the window averaged 17.3. With 4 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens November 2026 — about 2 months from now. This facility’s last Life Safety survey was March 2025. Facilities in KS are typically surveyed 20–22 months after the last one (median 21), measured over 298 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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9 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

3 of the 54 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 54 Life Safety citations above. The Physical Environment Index

F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in KS, and nationally. Surveyors differ markedly between states, so the KS figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	54
Median facility in KS	27
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
September 27, 2021	15
May 22, 2023	17
October 31, 2024	20
March 28, 2025	2

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0511	Have properly installed electrical wiring and gas equipment.	4	2025-03-28
K-0920	Ensure proper usage of power strips and extension cords.	4	2025-03-28
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	3	2024-10-31
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	3	2024-10-31
K-0222	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.	3	2024-10-31
K-0363	Install corridor and hallway doors that block smoke.	3	2024-10-31
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	3	2024-10-31
K-0353	Inspect, test, and maintain automatic sprinkler systems.	3	2024-10-31

What the citations cover

Citations by CMS category

Smoke Deficiencies 18
Egress Deficiencies 10
Miscellaneous Deficiencies 8
Gas, Vacuum, and Electrical Systems Deficiencies 7
Other 11

Citations by CMS category
Category	Citations
Smoke Deficiencies	18
Egress Deficiencies	10
Miscellaneous Deficiencies	8
Gas, Vacuum, and Electrical Systems Deficiencies	7
Construction Deficiencies	4
Services Deficiencies	4
Emergency Preparedness Deficiencies	3

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

March 28, 2025 — 2 citations

Citations issued on March 28, 2025
Tag	What the surveyor checks	Status
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (April 10, 2025)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (April 10, 2025)

October 31, 2024 — 20 citations

Citations issued on October 31, 2024
Tag	What the surveyor checks	Status
E-0037	Establish staff and initial training requirements.	Deficient, Provider has date of correction (December 16, 2024)
K-0100	Meet other general requirements.	Deficient, Provider has date of correction (December 19, 2024)
K-0161	Use approved construction type or materials.	Deficient, Provider has date of correction (December 19, 2024)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (December 19, 2024)
K-0222	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.	Deficient, Provider has date of correction (December 19, 2024)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (December 19, 2024)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (December 19, 2024)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (December 19, 2024)
K-0331	Construct fire resistant interior walls.	Deficient, Provider has date of correction (December 16, 2024)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (December 19, 2024)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (December 19, 2024)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (December 16, 2024)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (December 19, 2024)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (December 19, 2024)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (December 19, 2024)
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	Deficient, Provider has date of correction (December 16, 2024)
K-0753	Have restrictions on the use of highly flammable decorations.	Deficient, Provider has date of correction (December 16, 2024)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (December 16, 2024)
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	Deficient, Provider has date of correction (December 16, 2024)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (December 19, 2024)

May 22, 2023 — 17 citations

Citations issued on May 22, 2023
Tag	What the surveyor checks	Status
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (July 17, 2023)
K-0100	Meet other general requirements.	Deficient, Provider has date of correction (July 17, 2023)
K-0161	Use approved construction type or materials.	Deficient, Provider has date of correction (July 17, 2023)
K-0222	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.	Deficient, Provider has date of correction (July 17, 2023)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (July 17, 2023)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (July 17, 2023)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (July 17, 2023)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (July 17, 2023)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (July 17, 2023)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (July 17, 2023)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (July 17, 2023)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (July 17, 2023)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (July 17, 2023)
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	Deficient, Provider has date of correction (July 17, 2023)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (July 17, 2023)
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	Deficient, Provider has date of correction (July 17, 2023)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (July 17, 2023)

September 27, 2021 — 15 citations

Citations issued on September 27, 2021
Tag	What the surveyor checks	Status
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	Deficient, Provider has date of correction (December 20, 2021)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (December 20, 2021)
K-0222	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.	Deficient, Provider has date of correction (December 20, 2021)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (December 20, 2021)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (December 20, 2021)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (December 20, 2021)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (December 20, 2021)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (December 20, 2021)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (December 20, 2021)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (December 20, 2021)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (December 20, 2021)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (December 20, 2021)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (December 20, 2021)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (December 20, 2021)
K-0921	Ensure that testing and maintenance of electrical equipment is performed.	Deficient, Provider has date of correction (December 20, 2021)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.